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Trapping and resection of cortical MCA mycotic aneurysm in eloquent area

  • How I Do it - Vascular
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Abstract

Background

Mycotic aneurysms, although well recognized, are relatively rare intracranial vascular pathology. These aneurysms are typically located in distal cortical vessels. When these aneurysms are located in eloquent cerebral territories, they may become challenging to treat. Eloquent location may necessitate intraoperative angiographic evaluation to verify complete aneurysmal occlusion/obliteration and preservation of normal adjacent vasculture. Recently, ICG videoangiography has become a widely used intra-operative adjunct and is an important tool used to assess complete occlusion and vessel patency at the conclusion of clip reconstruction. In this report, we outline the comprehensive and concurrent utilization of both vascular imaging modalities to ensure safe and complete occlusion of a mycotic aneurysm.

Methods

We describe our experience with a patient with left M4, Rolandic, enlarging mycotic aneurysm that was treated in a comprehensive fashion with microsurgery and intra-operative angiography (IA).

Conclusions

ICG videoangiography, in combination with concurrent intraoperative angiography in the setting of complex vascular lesions, may support intraoperative decision-making and provide demonstration of complete occlusion in an immediate fashion. A hybrid operative suite allows for high-quality imaging confirming complete resection.

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References

  1. Gibo H, Carver CC, Rhoton AL Jr, Lenkey C, Mitchell RJ (1985) Microsurgical anatomy of the middle cerebral artery. J Neurosurg 54:151–169

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Authors and Affiliations

  1. Division of Neurosurgery, Maimonides Medical Center, 948 48th street, Brooklyn, NY, 11219, USA

    Erez Nossek

  2. Department of Neurosurgery, Hofstra North Shore–Long Island Jewish School of Medicine, North Shore University Hospital, Manhasset, NY, USA

    Avi Setton & David J. Chalif

  3. Department of Radiology, Hofstra North Shore–Long Island Jewish School of Medicine, North Shore University Hospital, Manhasset, NY, USA

    Avi Setton

Authors
  1. Erez Nossek
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  2. Avi Setton
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  3. David J. Chalif
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Corresponding author

Correspondence to Erez Nossek.

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Conflict of interests

We declare we have no conflict of interests.

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Key points

1) Critical attention not to injury the STA at skin incision.

2) When the direct cortical stimulation does not elicit any motor or other eloquent response the threshold for bypass is low.

3) When no collateral reconstitution is demonstrated and the cortical area is eliciting eloquent response, the STA can be used as a direct graft to the distal vessel.

4) The craniotomy is performed directly above the aneurysm with sufficient borders to allow for distal and proximal dissection and exposure of the distal and proximal segments.

5) Trapping should be done as close as possible to the aneurysm to avoid occlusion of long segments of the parent vessel to reduce the risk of localized ischemia.

6) A blood free field is mandatory to obtain meaningful ICG data.

7) Reconstitution of flow toward the distal parent vessel is demonstrated in a later phase than the normal arterial phase

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Nossek, E., Setton, A. & Chalif, D.J. Trapping and resection of cortical MCA mycotic aneurysm in eloquent area. Acta Neurochir 160, 579–582 (2018). https://doi.org/10.1007/s00701-017-3401-z

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  • DOI: https://doi.org/10.1007/s00701-017-3401-z

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