J Cerebrovasc Endovasc Neurosurg.  2024 Mar;26(1):37-45. 10.7461/jcen.2023.E2023.06.005.

Microsurgical treatment of distal middle cerebral artery aneurysm: A single-center review

• Jang T
• Kim ST
• Lee J
• Lee WH
• Lee KS
• Pyo SY
• Ko J
• Lee H
• Jeong YG

• KMID: 2554044
• DOI: http://doi.org/10.7461/jcen.2023.E2023.06.005

Abstract

Objective
To review the characteristics of distal middle cerebral artery (MCA) aneurysm treated by microsurgery, the detailed surgical options, and the clinical result.
Methods
We retrospectively reviewed cerebral aneurysm in the M2 and M3 segments of the MCA surgically treated between January 2015 and December 2022. The demographic data, aneurysm-related findings, type of surgical approach, surgical technique, and clinical outcomes of the enrolled patients were analyzed.
Results
Sixteen distal MCA aneurysms were treated with microneurosurgery (incidence, 1.0%; female, 12; mean age, 58.1 years; ruptured, three). Twelve aneurysms were in the M2 segment (insular segment), two aneurysms at the M2–M3 junction, and two aneurysms in the M3 segment (opercular segment). Twelve aneurysms were saccular (average size, 4.9 mm; multiplicity, 50%; average aneurysms, 3.0; partially thrombosed, 1; sidewall aneurysm, 2). Three aneurysms were fusiform, of which two were ruptured. Of the ruptured aneurysms, one was a ruptured dissecting aneurysm. The trans-sylvian and trans-sulcal approaches were used in fourteen and two patients, respectively. Neck clipping, wrap clipping, and surgical trapping were performed in twelve, one, and one patient, respectively. Proximal occlusion was performed in one patient. Bypass technique was required in two patients (neck clipping and proximal occlusion). The modified Rankin Score was 6 in the two patients with ruptured aneurysms. The remaining patients did not show further neurological deterioration after microneurosurgery.
Conclusions
Distal MCA aneurysms had a high incidence of being diagnosed with multiple other aneurysms and were relatively non-saccular.

Keyword

Distal; Intracranial aneurysm; Microsurgery; Middle cerebral artery

Figure

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  Fig. 1. Intraoperative field view of Case 10. (A) Fusiform aneurysm and afferent and efferent arteries can be identified through the wide sylvian dissection. Asterix indicates the fusiform aneurysm. The black arrow indicates an afferent artery of the aneurysm, and white arrow indicates the efferent arteries. (B) Temporary occlusion of the afferent artery (white arrow indicates a temporary clip in the afferent artery). (C) The connected afferent artery and one efferent artery close to the afferent artery, and the occluded trunk of the aneurysm with three clips. The white arrow indicates the anastomosis site of the other efferent artery with the parietal branch of the superficial temporal artery. (D) Indocyanine green angiography shows well preserved two efferent arteries (the yellow arrow indicates the blood flow from afferent artery to efferent artery, and the white arrow indicates the patent anastomosis site).

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  Fig. 2. Intraoperative field view of Case 12. (A) An approximately 15-mm-long dissecting aneurysm is identified after performing wide dissection of the sylvian cistern. The white arrow indicates the endpoint of the dissection. (B) Wrap clipping performed using bemsheet and three clips.

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  Fig. 3. Three-dimensional rotation angiography image and intraoperative field view of Case 12. Thrombosed large aneurysm in distal middle cerebral artery. (A) Three-dimensional rotation angiography image reveals non-thrombosed part of the aneurysm. (B) Indocyanine green angiography shows lack of blood flow in one branch after neck clipping (white arrow). (C) Computed tomography angiography after clipping reveals patency of the occluded branch. (D) Occluded distal branch anastomosed with the parietal branch of the superficial temporal artery. The white arrow indicates the anastomosis site.

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