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Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization.
J Neurosurg 2017; 127(3):463-479JN

Abstract

OBJECT Management of complex aneurysms of the middle cerebral artery (MCA) can be challenging. Lesions not amenable to endovascular techniques or direct clipping might require a bypass procedure with aneurysm obliteration. Various bypass techniques are available, but an algorithmic approach to classifying these lesions and determining the optimal bypass strategy has not been developed. The objective of this study was to propose a comprehensive and flexible algorithm based on MCA aneurysm location for selecting the best of multiple bypass options.

METHODS

Aneurysms of the MCA that required bypass as part of treatment were identified from a large prospectively maintained database of vascular neurosurgeries. According to its location relative to the bifurcation, each aneurysm was classified as a prebifurcation, bifurcation, or postbifurcation aneurysm.

RESULTS

Between 1998 and 2015, 30 patients were treated for 30 complex MCA aneurysms in 8 (27%) prebifurcation, 5 (17%) bifurcation, and 17 (56%) postbifurcation locations. Bypasses included 8 superficial temporal artery-MCA bypasses, 4 high-flow extracranial-to-intracranial (EC-IC) bypasses, 13 IC-IC bypasses (6 reanastomoses, 3 reimplantations, 3 interpositional grafts, and 1 in situ bypass), and 5 combination bypasses. The bypass strategy for prebifurcation aneurysms was determined by the involvement of lenticulostriate arteries, whereas the bypass strategy for bifurcation aneurysms was determined by rupture status. The location of the MCA aneurysm in the candelabra (Sylvian, insular, or opercular) determined the bypass strategy for postbifurcation aneurysms. No deaths that resulted from surgery were found, bypass patency was 90%, and the condition of 90% of the patients was improved or unchanged at the most recent follow-up.

CONCLUSIONS

The bypass strategy used for an MCA aneurysm depends on the aneurysm location, lenticulostriate anatomy, and rupture status. A uniform bypass strategy for all MCA aneurysms does not exist, but the algorithm proposed here might guide selection of the optimal EC-IC or IC-IC bypass technique.

Authors+Show Affiliations

Department of Neurosurgery and. Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California.Department of Neurosurgery and.Department of Neurosurgery and. Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California.Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California.Department of Neurosurgery and. Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

27813463

Citation

Tayebi Meybodi, Ali, et al. "Bypass Surgery for Complex Middle Cerebral Artery Aneurysms: an Algorithmic Approach to Revascularization." Journal of Neurosurgery, vol. 127, no. 3, 2017, pp. 463-479.
Tayebi Meybodi A, Huang W, Benet A, et al. Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization. J Neurosurg. 2017;127(3):463-479.
Tayebi Meybodi, A., Huang, W., Benet, A., Kola, O., & Lawton, M. T. (2017). Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization. Journal of Neurosurgery, 127(3), pp. 463-479. doi:10.3171/2016.7.JNS16772.
Tayebi Meybodi A, et al. Bypass Surgery for Complex Middle Cerebral Artery Aneurysms: an Algorithmic Approach to Revascularization. J Neurosurg. 2017;127(3):463-479. PubMed PMID: 27813463.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization. AU - Tayebi Meybodi,Ali, AU - Huang,Wendy, AU - Benet,Arnau, AU - Kola,Olivia, AU - Lawton,Michael T, Y1 - 2016/11/04/ PY - 2016/11/5/pubmed PY - 2019/8/16/medline PY - 2016/11/5/entrez KW - ACA = anterior cerebral artery KW - ATA = anterior temporal artery KW - CCA = common carotid artery KW - EC = extracranial KW - ECA = external carotid artery KW - IC = intracranial KW - ICA = internal carotid artery KW - LSA = lenticulostriate artery KW - MCA = middle cerebral artery KW - RAG = radial artery graft KW - SAH = sub-arachnoid hemorrhage KW - STA = superficial temporal artery KW - SVG = saphenous vein graft KW - complex aneurysm KW - extracranial–intracranial bypass KW - giant aneurysm KW - intracranial–intracranial bypass KW - mRS = modified Rankin Scale KW - orbitozygomatic craniotomy KW - pterional craniotomy KW - vascular disorders SP - 463 EP - 479 JF - Journal of neurosurgery JO - J. Neurosurg. VL - 127 IS - 3 N2 - OBJECT Management of complex aneurysms of the middle cerebral artery (MCA) can be challenging. Lesions not amenable to endovascular techniques or direct clipping might require a bypass procedure with aneurysm obliteration. Various bypass techniques are available, but an algorithmic approach to classifying these lesions and determining the optimal bypass strategy has not been developed. The objective of this study was to propose a comprehensive and flexible algorithm based on MCA aneurysm location for selecting the best of multiple bypass options. METHODS Aneurysms of the MCA that required bypass as part of treatment were identified from a large prospectively maintained database of vascular neurosurgeries. According to its location relative to the bifurcation, each aneurysm was classified as a prebifurcation, bifurcation, or postbifurcation aneurysm. RESULTS Between 1998 and 2015, 30 patients were treated for 30 complex MCA aneurysms in 8 (27%) prebifurcation, 5 (17%) bifurcation, and 17 (56%) postbifurcation locations. Bypasses included 8 superficial temporal artery-MCA bypasses, 4 high-flow extracranial-to-intracranial (EC-IC) bypasses, 13 IC-IC bypasses (6 reanastomoses, 3 reimplantations, 3 interpositional grafts, and 1 in situ bypass), and 5 combination bypasses. The bypass strategy for prebifurcation aneurysms was determined by the involvement of lenticulostriate arteries, whereas the bypass strategy for bifurcation aneurysms was determined by rupture status. The location of the MCA aneurysm in the candelabra (Sylvian, insular, or opercular) determined the bypass strategy for postbifurcation aneurysms. No deaths that resulted from surgery were found, bypass patency was 90%, and the condition of 90% of the patients was improved or unchanged at the most recent follow-up. CONCLUSIONS The bypass strategy used for an MCA aneurysm depends on the aneurysm location, lenticulostriate anatomy, and rupture status. A uniform bypass strategy for all MCA aneurysms does not exist, but the algorithm proposed here might guide selection of the optimal EC-IC or IC-IC bypass technique. SN - 1933-0693 UR - https://www.unboundmedicine.com/medline/citation/27813463/Bypass_surgery_for_complex_middle_cerebral_artery_aneurysms:_an_algorithmic_approach_to_revascularization_ L2 - https://thejns.org/doi/10.3171/2016.7.JNS16772 DB - PRIME DP - Unbound Medicine ER -