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Oliveira LB, Cieslak PH, Ferreira MY, Fuziki CK, Martins IC, Semione G, Marques GN, Palavani LB, Batista S, Rabelo NN, Koester SW, Bertani R, Welling LC, Lawton MT, Figueiredo EG. STA-MCA Double-Barrel Bypass: A Systematic Review of Technique and Single-Arm Meta-Analysis of Outcomes. Neurosurg Rev 2024; 47:341. [PMID: 39030432 DOI: 10.1007/s10143-024-02520-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/10/2024] [Accepted: 06/15/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Conventionally, one branch of the superficial temporal artery (STA) is utilized to revascularize the middle cerebral artery (MCA). However, there is the possibility of utilizing both branches of the STA when performing the bypass, characterizing the double-barrel (DB) STA-MCA bypass. Notably, a lack of studies evaluating this technique led the authors to conduct a systematic review and single-arm meta-analysis. METHODS PubMed, Embase and Web of Science were searched systematically for publications of DB-STA-MCA bypass on November 1st, 2023. The findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Case reports were not included for statistical analysis purposes. RESULTS The review included 408 patients and 534 bypasses from 34 studies. The main etiology was Moyamoya disease (64.6%), followed by cerebral ischemia (22.2%) and aneurysms (12.5%). The median of the mean follow-ups of each study was 12.8 months (range 1.5-87.9). The postoperative patency was 100%. The follow-up patency was 98% (95% CI: 96%-100%; I2 = 0%). The procedure-related mortality was 0% (95% CI: 0%-1%; I2 = 0%). Aneurysms obtained 87% (95% CI: 72%-100%; I2 = 4%) of good clinical outcomes, while Moyamoya disease yielded a rate of 70% (95% CI: 10%-100%; I2 = 97%). Ischemic complications occurred at a rate of 6% (95% CI: 2%-11%; I2 = 36%), while hemorrhagic occurred at 6% (95% CI: 1%-11%; I2 = 56%). Hyperperfusion syndrome rate was calculated as 18% (7%-30%; I2 = 55%) for Moyamoya disease. CONCLUSIONS The procedure appears to be safe, with excellent patency rates. The clinical efficacy for ischemic and Moyamoya diseases warrants further standardized robust investigation with a broader number of patients, and aneurysm studies are required to enhance sample sizes. The main complication for the Moyamoya subgroup is hyperperfusion syndrome.
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Affiliation(s)
- Leonardo B Oliveira
- Department of Neurosurgery, State University of Ponta Grossa, Ponta Grossa, PR, Brazil.
| | | | | | - Cassiano K Fuziki
- Department of Neurosurgery, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | - Italo C Martins
- Department of Neurosurgery, Federal University of Maranhão, São Luís, MA, Brazil
| | - Gabriel Semione
- Department of Neurosurgery, University of West of Santa Catarina, Joaçaba, SP, Brazil
| | | | - Lucca B Palavani
- Department of Neurosurgery, Max Planck University Center, Indaiatuba, SP, Brazil
| | - Sávio Batista
- Department of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, SP, Brazil
| | - Leonardo C Welling
- Department of Neurosurgery, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
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Rennert RC, Atai NA, Nguyen VN, Abedi A, Sternbach S, Chu J, Carey JN, Russin JJ. Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series. Oper Neurosurg (Hagerstown) 2024; 26:423-432. [PMID: 38084991 DOI: 10.1227/ons.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/29/2023] [Indexed: 03/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach. METHODS Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023. RESULTS Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved. CONCLUSION The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Nadia A Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Vincent N Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Sarah Sternbach
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Jason Chu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Department of Neurosurgery, Children's Hospital Los Angeles, Los Angeles , California , USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Jonathan J Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
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Liu P, Zhang H, Li P, Zhu W. 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 (Wien) 2023; 165:3717-3721. [PMID: 37878127 DOI: 10.1007/s00701-023-05846-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/14/2023] [Indexed: 10/26/2023]
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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Affiliation(s)
- Peixi Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, No.12 Wulumuqi Zhong Road, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
| | - Hongfei Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, No.12 Wulumuqi Zhong Road, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
| | - Peiliang Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, No.12 Wulumuqi Zhong Road, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, No.12 Wulumuqi Zhong Road, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
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Liu P, Shi Y, Li Z, Liu Y, Quan K, Liu Y, An Q, Zhu W. Interposition Intracranial-Intracranial Bypass Based on Anterior Cerebral Artery A1 Donor Anastomosis: Technical Advances, Outcomes, and Literature Review. Oper Neurosurg (Hagerstown) 2023; 24:322-329. [PMID: 36716013 DOI: 10.1227/ons.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/18/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The bypass technique is important for treating complex intracranial aneurysms and is infrequently performed. Intracranial-intracranial (IC-IC) bypass has shown many advantages in recent years. OBJECTIVE To review the techniques and outcomes of bypass based on anterior cerebral artery (ACA) A1 donor anastomosis in patients with intracranial aneurysm. METHODS We retrospectively reviewed the clinical and imaging data, surgical strategy, and follow-up outcomes of 7 patients treated from 2019 to 2022. Neurological function was assessed by the modified Rankin Scale (mRS). A literature review was performed using PubMed. RESULTS All 7 patients (3 male patients and 4 female patients; mean age, 50.4 ± 15.5 years) underwent aneurysm trapping or clipping using interposition IC-IC bypass based on ACA-A1 donor anastomosis. There were 6 middle cerebral artery (MCA) aneurysms and 1 posterior cerebral aneurysm in the series. One IC-IC bypass failed and was changed to extracranial-intracranial bypass. Three patients with MCA M1 aneurysm showed perforator-related infarction after the operation. The modified Rankin Scale score was 0 in 4 patients, 2 in 2 patients, and 1 in 1 patient. The long-term graft patency rate was 100%. CONCLUSION Interposition IC-IC bypass based on ACA-A1 donor anastomosis provides an effective way to achieve blood flow reconstruction in the treatment of complex aneurysms. This technique provides better caliber and volume compatibility and diminishes neck incision. Perforator-related infarction was the main complication because of involvement of the MCA M1 aneurysm location. Proximal clipping is preferred to avoid perforator-related infarction.
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Affiliation(s)
- Peixi Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Zongze Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yingjun Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yingtao Liu
- Department of Radiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Qingzhu An
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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Fourth-generation bypass and flow reversal to treat a symptomatic giant dolichoectatic basilar trunk aneurysm. Acta Neurochir (Wien) 2022; 164:2887-2892. [PMID: 35776222 DOI: 10.1007/s00701-022-05292-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Giant dolichoectatic basilar trunk aneurysms have an unfavorable natural history and are associated with high morbidity, but their neurosurgical treatment is complex and challenging. METHODS Flow reversal reconstruction with fourth-generation bypass and proximal vertebral artery clip occlusion is performed via orbitozygomatic craniotomy with the Kawase approach under rapid ventricular pacing. CONCLUSION Fourth-generation bypass is an innovative, technically challenging, and clinically effective tool in the treatment armamentarium for giant dolichoectatic basilar trunk aneurysms.
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Lawton MT, Graffeo CS, Srinivasan VM, Hendricks BK, Catapano JS, Scherschinski L, Lawrence PM, Larson Keil K, VanBrabant D, Hickman MD. Seven cavernomas and neurosurgical cartography, with an assessment of vascular waypoints. J Neurosurg 2022; 138:1148-1162. [PMID: 36282096 DOI: 10.3171/2022.8.jns221706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Christopher S. Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Visish M. Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Benjamin K. Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Peter M. Lawrence
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Kristen Larson Keil
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Danielle VanBrabant
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Michael D. Hickman
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
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Abramov I, Belykh E, Loymak T, Srinivasan VM, Labib MA, Preul MC, Lawton MT. Surgical Anatomy of the Middle Communicating Artery and Guidelines for Predicting the Feasibility of M2-M2 End-to-End Reimplantation. Oper Neurosurg (Hagerstown) 2022; 22:328-336. [PMID: 35315817 DOI: 10.1227/ons.0000000000000133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND M2-M2 end-to-end reimplantation that creates a middle communicating artery has recently been proposed as a reconstruction technique to treat complex aneurysms of the middle cerebral artery that are not amenable to clipping. OBJECTIVE To examine the surgical anatomy, define anatomic variables, and explore the feasibility of this bypass. METHODS Sixteen cadaver heads were prepared for bypass simulation. After the middle cerebral artery bifurcation was approached, the proximal insular (M2) segments and perforators were explored. To define the maximal distance between the M2 segments that allows the bypass to be performed, the M2 segments were mobilized and reimplanted in an end-to-end fashion. RESULTS Successful reimplantation was performed in all specimens. The mean maximal distance between the M2 segments to create the proposed reimplantation was 9.1 ± 3.2 mm. The mean vessel displacement was significantly greater for the superior (6.0 ± 2.3 mm) M2 segment than for the inferior (3.2 ± 1.4 mm) M2 segment (P < .001). CONCLUSION In this cadaveric study, the stumps of the M2 segments located at a distance of ≤9.1 mm could be approximated to create a feasible M2-M2 end-to-end anastomosis. Intraoperative inspection of the M2 segments and their perforators could allow further assessment of the feasibility of the procedure before final revascularization decisions are made.
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Affiliation(s)
- Irakliy Abramov
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Thanapong Loymak
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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8
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Song J, Mao Y. Giant Aneurysm Management. Adv Tech Stand Neurosurg 2022; 44:133-160. [PMID: 35107677 DOI: 10.1007/978-3-030-87649-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The treatment of giant aneurysms has always been a challenge in the field of neurovascular disease. Giant aneurysms are larger in size and are associated with thrombosis development and the calcification of the aneurysmal wall and neck, which often interfere with direct clipping. Most giant aneurysms have a wide neck with an incomplete thrombus, making complete embolization almost impossible. Giant aneurysms of different sites have entirely different hemodynamic characteristics. Moreover, aneurysms at the same site may exhibit very different hemodynamics among different individuals. Therefore, careful assessment of each case is required before and during treatment to develop and carry out an individualized treatment plan.
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Affiliation(s)
- Jianping Song
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China. .,Neurosurgical Institute of Fudan University, Shanghai, China. .,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China. .,National Center for Neurological Disorders, Shanghai, China.
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Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, Galzio R. Surgical Management of Giant Intracranial Aneurysms: Overall Results of a Large Series. World Neurosurg 2020; 144:e119-e137. [PMID: 32949801 DOI: 10.1016/j.wneu.2020.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review and discuss surgical treatment options for giant intracranial aneurysms (GIAs), focusing on indications, technical aspects, and results, along with some illustrative cases. METHODS We reviewed the data of 82 consecutive patients surgically managed between January 2000 and December 2019 for treatment of a GIA. RESULTS Male sex and hemorrhage at presentation were prevalent. The average follow-up was 81.2 ± 45 months. The anterior circulation was involved in 76.8% of GIAs. If the GIA showed a clear neck, minimal atherosclerosis, or intrasaccular thrombosis, and ≤2 branches arising from the neck, it was reconstructed. This procedure was possible in 78% of cases. The technique also involved temporary clipping, remodeling, and thrombectomy, as well as fragmentation techniques. Angioarchitectural features other than these techniques underwent bypass and aneurysm trapping. Most bypasses were extracranial to intracranial and high flow. Flow capacity, collateral circulation, and availability of the donor vessel mainly affected the choice of the type of bypass. Overall, successful exclusion of the GIA was 91.4%. The need for retreatment and complication rate were 3.6% and 19.5%, respectively. A good overall outcome (modified Rankin Scale score 0-3) was achieved in 84.2% of patients, and mortality was 10%. CONCLUSIONS Microneurosurgical techniques still maintain a significant role for most GIAs, with a high durability and acceptable rate of morbidity and mortality. Clip reconstruction is the first-line surgical treatment option, whereas bypass is indicated in cases of planned or unplanned sacrifice of the parent artery to prevent long-term ischemic complications.
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Affiliation(s)
- Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mattia Del Maestro
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, Cotignola, Italy
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