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Peeters SF, Colby GP, Kim WJ, Bae WI, Sparks H, Reitz K, Tateshima S, Jahan R, Szeder V, Nour M, Duckwiler GR, Vinuela F, Martin NA, Wang AC. Arterial Bypass in the Treatment of Complex Middle Cerebral Artery Aneurysms: Lessons Learned from Forty Patients. World Neurosurg 2024; 181:e261-e272. [PMID: 37832639 DOI: 10.1016/j.wneu.2023.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVE Complex middle cerebral artery (MCA) aneurysms incorporating parent or branching vessels are often not amenable to standard microsurgical clipping or endovascular embolization treatments. We aim to discuss the treatment of such aneurysms via a combination of surgical revascularization and aneurysm exclusion based on our institutional experience. METHODS Thirty-four patients with complex MCA aneurysms were treated with bypass and aneurysm occlusion, 5 with surgical clipping or wrapping only, and 1 with aneurysm excision and primary reanastomosis. Bypasses included superficial temporal artery (STA)-MCA, double-barrel STA-MCA, occipital artery-MCA, and external carotid artery-MCA. After bypass, aneurysms were treated by surgical clipping, Hunterian ligation, trapping, or coil embolization. RESULTS The average age at diagnosis was 46 years. Of the aneurysms, 67% were large and most involved the MCA bifurcation. Most bypasses performed were STA-MCA bypasses, 12 of which were double-barrel. There were 2 wound-healing complications. All but 2 of the aneurysms treated showed complete occlusion at the last follow-up. There were 3 hemorrhagic complications, 3 graft thromboses, and 4 ischemic insults. The mean follow-up was 73 months. Of patients, 83% reported stable or improved symptoms from presentation and 73% reported a functional status (Glasgow Outcome Scale score 4 or 5) at the latest available follow-up. CONCLUSIONS Cerebral revascularization by bypass followed by aneurysm or parent artery occlusion is an effective treatment option for complex MCA aneurysms that cannot be safely treated by standard microsurgical or endovascular techniques. Double-barrel bypass consisting of 2 STA branches to 2 MCA branches yields adequate flow replacement in most cases.
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Affiliation(s)
- Sophie F Peeters
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Whi Inh Bae
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Hiro Sparks
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kara Reitz
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Reza Jahan
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Viktor Szeder
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - May Nour
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gary R Duckwiler
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Fernando Vinuela
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Neil A Martin
- Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California, USA
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
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Peeters SM, Colby GP, Kim WJ, Bae WI, Sparks H, Reitz K, Tateshima S, Jahan R, Szeder V, Nour M, Duckwiler GR, Vinuela F, Martin NA, Wang AC. Proximal Internal Carotid Artery Occlusion and Extracranial-Intracranial Bypass for Treatment of Fusiform and Giant Internal Carotid Artery Aneurysms. World Neurosurg 2023; 180:e494-e505. [PMID: 37774787 DOI: 10.1016/j.wneu.2023.09.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE To discuss the treatment of intracranial fusiform and giant internal carotid artery (ICA) aneurysms via revascularization based on our institutional experience. METHODS An institutional review board-approved retrospective analysis was performed of patients with unruptured fusiform and giant intracranial ICA aneurysms treated from November 1991 to May 2020. All patients were evaluated for extracranial-intracranial (EC-IC) bypass and ICA occlusion. RESULTS Thirty-eight patients were identified. Initially, patients failing preoperative balloon test occlusion were treated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and concurrent proximal ICA ligation. We then treated them with STA-MCA bypass, followed by staged balloon test occlusion, and, if they passed, endovascular ICA coil occlusion. We treat all surgical medically uncomplicated patients with double-barrel STA-MCA bypass and concurrent proximal ICA ligation. The mean length of follow-up was 99 months. Symptom stability or improvement was noted in 85% of patients. Bypass graft patency was 92.1%, and all surviving patients had patent bypasses at their last angiogram. Aneurysm occlusion was complete in 90.9% of patients completing proximal ICA ligation. Three patients experienced ischemic complications and 4 patients experienced hemorrhagic complications. CONCLUSIONS Not all fusiform intracranial ICA aneurysms require intervention, except when life-threatening rupture risk is high or symptomatic management is necessary to preserve function and quality of life. EC-IC bypass can augment the safety of proximal ICA occlusion. The rate of complete aneurysm occlusion with this treatment is 90.9%, and long-term bypass graft-related complications are rare. Perioperative stroke is a major risk, and continued evolution of treatment is required.
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Affiliation(s)
- Sophie M Peeters
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Whi Inh Bae
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Hiro Sparks
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kara Reitz
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Reza Jahan
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Viktor Szeder
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - May Nour
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gary R Duckwiler
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Fernando Vinuela
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Neil A Martin
- Pacific Neuroscience Institute, Santa Monica, California, USA
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
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