Microneurosurgical management of middle cerebral artery bifurcation aneurysms

doi:10.1016/j.surneu.2006.11.056

Surgical Neurology

Volume 67, Issue 5, May 2007, Pages 441-456

https://doi.org/10.1016/j.surneu.2006.11.056 Get rights and content

Abstract

Background

Of the MCA aneurysms, those located at the main bifurcation of the MCA (MbifA) are by far the most frequent. The purpose of this article is to review the practical anatomy, preoperative planning, and avoidance of complications in the microsurgical dissection and clipping of MbifAs.

Methods

This review, and the whole series on intracranial aneurysms, is mainly based on the personal microneurosurgical experience of the senior author (JH) in 2 Finnish centers (Helsinki and Kuopio), which serve without patient selection the catchment area in southern and eastern Finland.

Results

These 2 centers have treated more than 10 000 patients with intracranial aneurysm's since 1951. In the Kuopio Cerebral Aneurysm Data Base of 3005 patients with 4253 aneurysms, MbifAs formed 30% of all ruptured aneurysms, 36% of all unruptured aneurysms, 35% of all giant aneurysms, and 89% of all MCA aneurysms. Importantly, in 45%, rupture of MbifA caused an ICH.

Conclusions

Middle cerebral artery bifurcation aneurysms are often broad necked and may involve one or both branches of the bifurcation (M2s). The anatomical and hemodynamic features of MbifAs make them usually more favorable for microneurosurgical treatment. In population-based services, MbifAs are frequent targets of elective surgery (unruptured), acute surgery (ruptured), and emergency surgery (large ICH), even advanced approaches (giant). The challenge is to clip the neck adequately, without neck remnants, while preserving the bifurcational flow.

Introduction

Of the MCA aneurysms, those located at the main bifurcation of the MCA (MbifA) (Table 1) are by far the most frequent [11], [20], [21], [39], [40], [45], [47], [48], [49], [58], [59], [78]. In population-based services, MbifAs are frequent targets of elective surgery (unruptured), acute surgery (ruptured), and emergency surgery (large ICH), even advanced approaches (giant). Middle cerebral artery bifurcation aneurysms are often broad necked and may be dysmorphic in shape involving 1 or both branches of the bifurcation (M2s). The challenge is to clip the neck adequately, without neck remnants, while preserving the bifurcational flow.

This review, and the whole series on intracranial aneurysms, is intended for neurosurgeons who are subspecializing in neurovascular surgery. The purpose is to review the practical anatomy, preoperative planning, and avoidance of complications in the microsurgical dissection and clipping of MbifAs.

This review is mainly based on the personal microneurosurgical experience of the senior author (JH) in 2 Finnish centers (Helsinki and Kuopio), which serve without selection the catchment area in the southern and eastern Finland. These two centers have treated more than 10 000 patients with aneurysm since 1951.

Section snippets

Occurrence of MbifAs

Middle cerebral artery aneurysms are most frequently located at the main bifurcation of the MCA (MbifAs) [11], [20], [39], [40], [45], [47], [48], [49], [58], [59], [78]. Middle cerebral artery bifurcation aneurysms comprised 82.6% of the MCA aneurysms of Yaşargil's series [78]. Table 2, Table 3, Table 4, Table 5 presents the clinical data of patients with MbifA in a consecutive and population-based series of 3005 patients with 4253 intracranial aneurysms from 1977 to 2005 in the Kuopio

Microsurgical anatomical considerations of MbifAs

Middle cerebral artery aneurysms can be classified into proximal (M1A), bifurcational (MbifA), and distal types (MdistA) (Table 1). Proximal MCA aneurysms or M1As are located in the main trunk (M1), between the bifurcation of the ICA and the main bifurcation of MCA [6]. Middle cerebral artery bifurcation aneurysm is the focus of the present article. Distal MCA aneurysm, originating from the M2 or more distal branches of MCA, will be the focus of a separate article.

Middle cerebral artery

Imaging of MbifAs

Digital subtraction angiography is still the present gold standard in many centers. Multislice helical CTA is the primary modality in our centers for several reasons: noninvasive and quick imaging; comparable sensitivity and specificity to DSA in aneurysms larger than 2 mm [9], [17], [25], [33], [35], [61], [64], [65], [70], [72], [73], [74], [76], [80]; disclosure of calcifications in the walls of arteries and the aneurysm; quick reconstruction of 3D images that, for example, show the

Microsurgical strategy with MbifAs

In population-based neurovascular services, MbifAs are frequent targets of elective surgery (unruptured), acute surgery (ruptured), and emergency surgery (large ICH), even advanced approaches (giant). Middle cerebral artery bifurcation aneurysms are also frequent as associated aneurysms. Middle cerebral artery bifurcation aneurysms are often broad necked and may involve one or both M2s. Other branches may be attached to their wall, and, less frequently, perforators may be at risk when

General principles

Usually, it is not advisable to dissect the dome completely before applying the pilot clip, but sharp dissection of the arteries around and adjacent to the base is crucial. M1, M2s, and adjacent and perforating branches near the bifurcation should be unhurriedly, clearly, and painstakingly visualized before final clipping of the MbifA neck (Fig. 8).

Dissection under temporary clipping of arteries

Frequent use of temporary clips allows for safe and sharp dissection of MbifAs and the adjacent arteries. The duration of each temporary occlusion

Intertruncal MbifA

Intertruncal MbisAs project superiorly in the coronal (AP) and posteriorly in the axial plane (Fig. 3). The dome projects to the same direction as the M2 trunks and lies between them. The base is often broad and involves the origin of one M2 (the thicker one) or both. The attachment of M2s to the base and the proximal part of the fundus makes intertruncal MbifAs demanding to clip adequately.

Inferior MbifA

Inferior MbifAs project inferiorly in the coronal (AP) and anteriorly toward the sphenoid ridge, in the axial plane. Consequently, the dome is projecting to the temporal aspect of the surgeon's view inside the sylvian fissure (Fig. 4).

Lateral MbifA

Lateral MbifAs project laterally in the coronal (AP) plane and in the axial plane. In the surgeon's view, lateral MbifAs follow the same direction as the M1 trunk (Fig. 5).

Insular MbifA

Insular MbifA projects medially in the AP (coronal) plane and medially in the axial plane. In the surgeon's view, insular MbifAs project behind the bifurcation, toward the insular surface (Fig. 6).

Complex MbifA

In this special group of dysmorphic and large or giant aneurysms, the growth of the dome is usually multidirectional and the relation of the base with M1 and M2s may be a combination of other types (Fig. 7).

Head positioning and craniotomy should be tailored according to the 3D relation of aneurysm with the bifurcation. After careful dissection, temporary clips are applied to M1 and both M2s. Softened dome may be opened and reshaped by bipolar coagulation (see above). Usually, adequate clipping

Associated aneurysms

Middle cerebral artery bifurcation aneurysms are often associated with other aneurysms, 44% of all patients with MbifA and 30% of those with ruptured MbifA had at least one additional aneurysm (Table 4). Bilateral (mirror) MbifAs were seen in 12% of the patients with MbifA. Our strategy is to clip all aneurysms that can be exposed through the same craniotomy [7], [8], [30], [71], [78]. This may not be advisable if the clipping of the ruptured aneurysm is difficult or the brain is swollen owing

Giant MbifAs

Middle cerebral artery is the most frequent site for giant aneurysms. In the Kuopio series, 4% of all MbifAs and 6% of ruptured MbifAs were giant, with greater than 25 mm in diameter (Table 3). Combined 3D DSA, CTA, and MRI data are necessary for a complete view on the vascular anatomy, intraluminal thrombus, and thickness and calcifications of the wall [21], [55], [60]. In published series, direct clipping was possible in the majority of cases (38%-71%) [14], [15], [27], [28], [29], [36], [41]

Fusiform MbifAs

Often, reconstruction of a fusiform aneurysm may be achieved by clip(s) excluding the “beer belly” from the circulation. For the rest, other techniques like a sling around the aneurysm with a clip and/or wrapping with cottonoids and glue to enhance the scarring have been tried. However, bypass operation followed by occlusion of the parent artery is the treatment of choice.

Bypass operations and arteriotomies

Preoperative high-flow EC-IC or IC-IC bypass using the ELANA or SELANA techniques [54], or low-flow superficial temporal artery–MCA bypass, may be considered in large or giant MbifAs, when the exclusion of the neck from the parent and branching arteries cannot be performed [21]. A comprehensive neurovascular team should be prepared to perform intraoperative arteriotomies, for example, to remove coils or thrombi, and intraoperative EC-IC or IC-IC bypasses, also in case of emergency.

Clipping after inappropriate clipping or failed coiling

The best moment to treat aneurysm is the first moment. Intraoperative verification of clipping by angiography reduces the rate of inappropriate clipping. Scarring after improper clipping or occlusive material inside the aneurysm after failed coiling makes later microsurgical occlusion complicated and sometimes impossible. To reduce redo surgeries, aneurysms should be treated in specialized centers with a high flow of cases and an experienced team mastering exosurgery and endosurgery [34].

Acknowledgments

We thank Mr Ville Kärpijoki for excellent technical assistance.

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Citation Excerpt :
On the one hand, the peripheral location of MCA bifurcation aneurysms provides a good microsurgical access. On the other hand, MCA bifurcation aneurysms are often wide-necked and major arterial branches arise at their base (Figure 1), which can pose a challenge for endovascular treatment.6-8 However, with the advances of neurointerventional techniques, a growing number of these aneurysms become amenable to endovascular means.9-11
Although intracranial aneurysms are increasingly treated endovascularly, microsurgical clipping has been the standard approach for middle cerebral artery (MCA) aneurysms. We compared microsurgical clipping and state-of-the-art endovascular treatment of unruptured MCA bifurcation aneurysms treated at a neurovascular center following a “coil-first” policy.
This single-center study included 148 patients treated for 160 unruptured MCA bifurcation aneurysms. Technical success, complications, clinical outcome, and angiographic results were retrospectively compared.
Microsurgical clipping was performed for 120 MCA aneurysms (75%) and endovascular treatment for 40 (25%; conventional coiling: 8, stent-assisted coiling: 16, balloon-assisted coiling: 3, and flow-disruption: 13). Technical treatment success was higher in the clipping group (100%) than in the endovascular group (92.5%, P = 0.015). Overall, complications occurred in 16.7% for clipping and in 20.0% for endovascular treatment (P = 0.631). Major ischemic stroke rates were 4.2% in the clipping group and 7.5% in the endovascular group (P = 0.414). At 6 months, a favorable outcome was obtained by 99.2% after clipping and 95.0% after endovascular treatment (P = 0.154). The 6-month complete aneurysm occlusion rates were by trend higher in the clipping group (89.2%) than in the endovascular group (75.9%, P = 0.078).
Microsurgical clipping was associated with a higher technical success rate and tendentially higher complete occlusion than endovascular treatment, with no additional morbidity and similar clinical outcome. On the basis of these results, clipping proves to be the standard treatment option for MCA bifurcation aneurysms. However, endovascular treatment represents a safe and efficient alternative treatment option for patients.

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Aneurysm–Rainbow Team/HelsinkiMicroneurosurgical management of middle cerebral artery bifurcation aneurysms

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Occurrence of MbifAs

Microsurgical anatomical considerations of MbifAs

Imaging of MbifAs

Microsurgical strategy with MbifAs

General principles

Dissection under temporary clipping of arteries

Intertruncal MbifA

Inferior MbifA

Lateral MbifA

Insular MbifA

Complex MbifA

Associated aneurysms

Giant MbifAs

Fusiform MbifAs

Bypass operations and arteriotomies

Clipping after inappropriate clipping or failed coiling

Acknowledgments

Clin Neurol Neurosurg

Surg Neurol

Surg Neurol

Neurosurg Clin N Am

Surg Neurol

J Clin Neurosc

Surg Neurol

Surg Neurol

Eur J Radiol

Clin Radiol

Management morbidity and mortality of poor-grade aneurysm patients

J Neurosurg

Reconstruction of the MCA bifurcation after excision of a giant aneurysm. Technical note

J Neurosurg

Ruptured middle cerebral artery aneurysm with intracerebral hemorrhage in younger patients appearing moribund: emergency operation?

Neurosurgery

Nuances of middle cerebral artery aneurysm microsurgery

Neurosurgery

Anatomical and technical aspects of the contralateral approach for multiple aneurysms

Acta Neurochir

Spiral CT angiography

Am J Radiol

Giant intracranial aneurysms: experience with surgical treatment in 174 patients

Clin Neurosurg

Remodeling of saccular cerebral artery aneurysm wall is associated with rupture: histological analysis of 24 unruptured and 42 ruptured cases

Stroke

Growth factor receptor expression and remodeling of saccular cerebral artery aneurysm walls: implications for biological therapy preventing rupture

Neurosurgery

Giant aneurysms of the proximal anterior cerebral artery: report of three cases

Neurosurgery

Giant aneurysms of the anterior circle of Willis: management outcome of open microsurgical treatment

Surg Neurol

Microsurgical anatomy of the middle cerebral artery

J Neurosurg

Three-dimensional computerized tomography angiography in the diagnosis of cerebrovascular disease

J Neurosurg

Acute surgery for intracerebral haematomas caused by rupture of an intracranial arterial aneurysm. A prospective randomized study

Acta Neurochir

Lateral supraorbital approach as an alternative to the classical pterional approach

Acta Neurochir

Aneurysms in the middle cerebral artery

Surgical management of middle cerebral artery aneurysms

Neurosurgery

Superior temporal gyrus approach to middle cerebral artery aneurysms technique and results

Neurosurgery

Saccular aneurysms of the proximal (M1) segment of the middle cerebral artery

Neurosurgery

Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention

N Engl J Med

Detection of intracranial aneurysms with two-dimensional and three-dimensional multislice helical computed tomographic angiography

Neurosurgery

Operative anatomy and classification of the sylvian veins for the distal transsylvian approach

Neurol Med Chir

Surgical management of giant intracranial aneurysms: experience with 171 patients

Clin Neurosurg

Aneurysm–Rainbow Team/Helsinki
Microneurosurgical management of middle cerebral artery bifurcation aneurysms