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Aneurysmoraphy or bypass? Surgical strategy for large M1 bifurcation aneurysm involving two branches based on vessel wall high-resolution MRI and intraoperative angiography

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Abstract

Background

Middle cerebral artery (MCA) M1 bifurcation aneurysms are common because of hemodynamic. For regular-shaped and small aneurysms, direct clipping is optimal. Aneurysmoraphy or bypass blood flow reconstruction are most commonly used in large aneurysm clipping. Based on preoperative vessel wall high-resolution magnetic resonance imaging (VW-HRMRI) and intraoperative angiography, an appropriate surgery strategy could be decided.

Method

We report a case of large MCA M1 bifurcation aneurysm aneurysmoraphy according to preoperative VW-HRMRI. Intraoperative digital subtraction angiography (DSA) showed an aneurysm neck remnant, and we adjusted clips according to intraoperative DSA. This patient recovered well with a modified Rankin scale of 0 at discharge.

Conclusion

This case demonstrates that preoperative VWHRMRI could supply more aneurysm characteristics for direct aneurysmoraphy. Intraoperative DSA effectively reduces the possibility of aneurysm remnant.

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References

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Funding

This study was supported by the Clinical Research Plan of SHDC (No. SHDC2020CR2034B to WZ) and Special Clinical Research Project in Health Industry of Shanghai Municipal Health Commission (No. 20224Y0072 to PL).

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, No.12 Wulumuqi Zhong Road, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Peiliang Li & Wei Zhu

  2. National Center for Neurological Disorders, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Peiliang Li & Wei Zhu

  3. Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Peiliang Li & Wei Zhu

  4. Neurosurgical Institute of Fudan University, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Peiliang Li & Wei Zhu

  5. Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Peiliang Li & Wei Zhu

Authors
  1. Peixi Liu
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  2. Hongfei Zhang
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  3. Peiliang Li
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  4. Wei Zhu
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Contributions

Peixi Liu: participants in surgery, conception and design of study, provision of study material, collection and/or assembly of data, manuscript writing, and final approval of manuscript.

Hongfei Zhang: literature collection and collation.

Peiliang Li: participants in surgery, conception, and design of study.

Wei Zhu: conception and design of the study and revision and final approval of the manuscript.

The authors thank Zongze Li for surgery participants, Yingtao Liu for imaging processing, and Yang Xiao for intraoperative electrophysiological monitoring support.

Corresponding author

Correspondence to Wei Zhu.

Ethics declarations

Ethics approval

Not applicable.

Research involving human participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Huashan Hospital Institutional Review Board (HIRB), Fudan University, Shanghai, China.

Consent to participate

The patient gave approval for this publication.

Consent for publication

All authors declare that they have no competing financial interest.

Conflict of interest

The authors declare no competing interests.

Additional information

Key points

1. Preoperative VW-HRMRI helps operators assess aneurysm neck and sac atherosclerosis.

2. A high intrasac signal in VW-HRMRI indicates the feasibility of direct clipping or aneurysmoraphy.

3. Bypass should always be prepared in large complex MCA bifurcation aneurysm.

4. STA blood volume needs to be assessed before surgery.

5. Intracranial-intracranial bypass shows more advantages than extracranial-intracranial bypass, especially in young patients.

6. SEP and MEP monitoring are quick measures to determine temporary occlusion tolerance and blood flow changes.

7. ICG provides basic assessment for branch patency, but it cannot show aneurysm remnant.

8. Endoscopy detection is an alternative method after aneurysmoraphy.

9. DSA and three-dimensional rotation construction were the gold standards for complete clipping.

10. At least one DSA long-term follow-up is required after discharge.

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The first two authors, PL and HZ, contributed to this article equally.

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Liu, P., Zhang, H., Li, P. et al. Aneurysmoraphy or bypass? Surgical strategy for large M1 bifurcation aneurysm involving two branches based on vessel wall high-resolution MRI and intraoperative angiography. Acta Neurochir 165, 3717–3721 (2023). https://doi.org/10.1007/s00701-023-05846-6

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  • DOI: https://doi.org/10.1007/s00701-023-05846-6

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