Microsurgical Management of the Middle Cerebral Artery Bifurcation Aneurysms: An Anatomic Feasibility Study

Background: The proper head positioning decreases the surgical complications by enabling a better surgical maneuverability. Middle cerebral artery (MCA) bifurcation aneurysms have been classified by Dashti et al. [Surg Neurol. 2007 May;67(5):441–56] as the intertruncal, inferior, lateral, insular, and complex types based on dome projection. Our aim was to identify the optimum head positions and to explain the anatomic variables, which may affect the surgical strategy of MCA bifurcation aneurysms. Methods: The lateral supraorbital approach bilaterally was performed in the 4 cadaveric heads. All steps of the dissection were recorded using digital camera. Results: The distal Sylvian fissure (SF) dissection may be preferred for insular type and the proximal SF dissection may be preferred for all other types. Fifteen degrees head rotation was found as the most suitable position for the intertruncal, lateral type and subtype of complex aneurysms related with superior trunk. Thirty degrees head rotation was found the most suitable position for the inferior type, insular type, and subtype of complex aneurysms related with inferior trunk. Conclusions: The head positioning in middle cerebral bifurcation aneurysms surgery is a critical step. It should be tailored according to the projection and its relationship with the parent vessels of the middle cerebral bifurcation.

Download Full-text

Comparison between modified lateral supraorbital approach and pterional approach in the surgical treatment of middle cerebral artery aneurysms

Chinese Neurosurgical Journal ◽

10.1186/s41016-018-0110-2 ◽

2018 ◽

Vol 4 (1) ◽

Author(s):

Zhouqing Chen ◽

Xiaoou Sun ◽

Tai Lu ◽

Zhengyang Lu ◽

Ming Jiang ◽

...

Keyword(s):

Surgical Treatment ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Pterional Approach ◽

Supraorbital Approach ◽

Lateral Supraorbital Approach ◽

Middle Cerebral Artery Aneurysms ◽

Modified Lateral Supraorbital Approach

Download Full-text

Subclavian to middle cerebral artery saphenous vein bypass graft

Journal of Neurosurgery ◽

10.3171/jns.1980.53.4.0465 ◽

1980 ◽

Vol 53 (4) ◽

pp. 465-469 ◽

Cited By ~ 74

Author(s):

Robert F. Spetzler ◽

Robert S. Rhodes ◽

Richard A. Roski ◽

Matt J. Likavec

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Saphenous Vein ◽

Artery Bypass ◽

Bypass Graft ◽

Superficial Temporal Artery ◽

Head Rotation ◽

Temporal Artery ◽

Additional Advantage ◽

Content Type

✓ A variation of an extracranial-intracranial arterial bypass is presented. The subclavian artery is used as the donor vessel and the saphenous vein as the graft; thus, a bypass to a cortical branch of the middle cerebral artery can be accomplished. The advantage of this modification is that the saphenous vein, when tunneled subcutaneously behind the ear, is positioned in a straight line from the donor to the recipient vessel. Since the vein lies in the axis of head rotation, turning of the head causes little displacement of the graft, as opposed to a graft from the common carotid artery to the middle cerebral artery. An additional advantage over the superficial temporal artery to middle cerebral artery bypass is the large flow obtained immediately after anastomosis.

Download Full-text

Current Status of Superficial Temporal Artery-Middle Cerebral Artery (STA-MCA) Bypass as Cerebral Revascularization for Occlusive Lesions and Complex Aneurysms in the Anterior Circulation(Current Strategies of Extracranial-Intracranial Bypass Surgery)

Japanese Journal of Neurosurgery ◽

10.7887/jcns.17.579 ◽

2008 ◽

Vol 17 (8) ◽

pp. 579-586

Author(s):

Koji Iihara ◽

Yusuke Egashira ◽

Takeshi Funaki ◽

Norio Nakajima ◽

Jun C Takahashi ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Bypass Surgery ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Cerebral Revascularization ◽

Current Status ◽

Anterior Circulation ◽

Complex Aneurysms

Download Full-text

Orthogonal Interlocking Tandem Clipping Technique for the Reconstruction of Complex Middle Cerebral Artery Aneurysms

Operative Neurosurgery ◽

10.1227/01.neu.0000222818.42200.bb ◽

2006 ◽

Vol 59 (suppl_4) ◽

pp. ONS-347-ONS-352 ◽

Cited By ~ 7

Author(s):

Richard E. Clatterbuck ◽

Robert M. Galler ◽

Rafael J. Tamargo ◽

David J. Chalif

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Vascular Anatomy ◽

Line Of Sight ◽

Aneurysm Clip ◽

Neurological Outcomes ◽

Complex Aneurysms ◽

Clinical Presentations ◽

Clipping Technique ◽

Middle Cerebral Artery Aneurysms

Abstract OBJECTIVE: Complex aneurysms arising at the middle cerebral artery (MCA) bifurcation frequently present a microsurgical challenge to effectively obliterate while maintaining patency of the distal MCA branches. These aneurysms are often multilobed, with their long axis aligned with the long axis of the M1 trunk, placing the dome of the aneurysm in the surgeons' line of sight, preventing an unobstructed view of the entire bifurcation and proximal M1 segment. MCA aneurysms often have a broad neck, splaying the bifurcation. An orthogonal interlocking tandem clipping technique, maximizing the use of fenestrated aneurysm clips, is presented as a means to completely obliterate the aneurysm and simultaneously “reconstruct” the MCA bifurcation. CLINICAL PRESENTATIONS AND INTERVENTION: Fifteen complex MCA aneurysms were treated using an interlocking tandem clipping technique. In its simplest application, the blades of the initial aneurysm clip are incorporated into the fenestration of the second clip. Obliteration of the residual aneurysm is achieved with the blades of the second, fenestrated clip. RESULTS: Satisfactory aneurysm obliteration and reconstruction of the MCA bifurcation was achieved in all cases using this technique, with excellent neurological outcomes. CONCLUSION: Morphologically complex multilobed MCA aneurysms can be effectively clipped with “reconstruction” of the normal vascular anatomy using a tandem interlocking clipping technique. A fenestrated clip is used to incorporate the blades of the initial clip, while obliterating the remainder of the aneurysm.

Download Full-text

Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Grafting for Cerebral Revascularization

Neurosurgery ◽

10.1227/01.neu.0000129549.99061.94 ◽

2004 ◽

Vol 55 (2) ◽

pp. 395-399 ◽

Cited By ~ 41

Author(s):

John E. Wanebo ◽

Joseph M. Zabramski ◽

Robert F. Spetzler

Keyword(s):

Brain Tumors ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Bypass Grafting ◽

Extensive Experience ◽

Artery Bypass Grafting ◽

Complex Aneurysms

Abstract SUPERFICIAL TEMPORAL ARTERY-to-middle cerebral artery bypass procedures are an important tool in the armamentarium of cerebrovascular surgeons for the treatment of carotid occlusion and revascularization for complex aneurysms and brain tumors. This article enumerates the essential steps in performing superficial temporal artery-to-middle cerebral artery bypass procedures. The nuances of this technique reflect the extensive experience of the senior authors (RFS, JMZ).

Download Full-text

Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization

Journal of Neurosurgery ◽

10.3171/2016.7.jns16772 ◽

2017 ◽

Vol 127 (3) ◽

pp. 463-479 ◽

Cited By ~ 33

Author(s):

Ali Tayebi Meybodi ◽

Wendy Huang ◽

Arnau Benet ◽

Olivia Kola ◽

Michael T. Lawton

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Algorithmic Approach ◽

Complex Aneurysms ◽

Bypass Patency ◽

Mca Aneurysm ◽

In Situ Bypass ◽

Middle Cerebral Artery Aneurysms

OBJECTManagement 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.METHODSAneurysms 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.RESULTSBetween 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.CONCLUSIONSThe 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.

Download Full-text

“Picket Fence” clipping technique for large and complex aneurysms

Neurosurgical FOCUS ◽

10.3171/2015.7.focusvid.14632 ◽

2015 ◽

Vol 39 (videosuppl1) ◽

pp. V17 ◽

Cited By ~ 7

Author(s):

Jason M. Davies ◽

Michael T. Lawton

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Link Type ◽

Complex Aneurysms ◽

Complex Anatomy ◽

Picket Fence ◽

Mca Aneurysm ◽

Clipping Technique

The “picket fence” clipping technique is a method for clipping large aneurysms when conventional clipping across the neck is not feasible, either due to complex anatomy, atherosclerosis, calcification, or compromise of branch origins. This has also been described as a dome fenestration tube. Parallel straight clips, simple and/or fenestrated, are stacked vertically from dome to neck with the tips reconstructing the neck. In this video, the “picket fence” clipping technique is demonstrated on a large middle cerebral artery (MCA) aneurysm. A total of 14 clips reconstructed the neck, completely occluding the aneurysm and preserving outflow in all branch vessels.The video can be found here: http://youtu.be/0N5rYR6Op8Y.

Download Full-text

An ultrastructural analysis of the sympathetic innervation of the rabbit ear artery and middle cerebral artery and their branches

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100125075 ◽

1992 ◽

Vol 50 (1) ◽

pp. 934-935

Author(s):

John T. Dodge ◽

John A. Bevan

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Sympathetic Innervation ◽

Electrical Field Stimulation ◽

Rabbit Ear Artery ◽

Electrical Field ◽

Functional Differences ◽

Ear Artery ◽

Rabbit Ear ◽

Vascular Beds

Unlike many peripheral vascular beds, the sympathetic nervous system exerts little control on cerebral blood flow. The contractile response of isolated rabbit middle cerebral artery (MCA) segments to electrical field stimulation of its intramural nerves is less than in a similar-sized artery from the ear. This study was undertaken to characterize and compare the perivascular neuromuscular relationships and innervation density of similar-sized arteries varying in diameter from these two different regional arterial beds to see if there were structural correlates for these functional differences.

Download Full-text