Ruptured Middle Cerebral Artery Aneurysm with Intracerebral Hemorrhage in Younger Patients Appearing Moribund: Emergency Operation?

Neurosurgery ◽  
1987 ◽  
Vol 20 (6) ◽  
pp. 925-929 ◽  
Author(s):  
Lennart Brandt ◽  
Bengt Sonesson ◽  
Bengt Ljunggren ◽  
Hans Säveland
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Aneurysm ◽  
Giant Aneurysm ◽  
Emergency Operation ◽  
Neurological Deficits ◽  
Deep Coma ◽  
Intracerebral Hematoma ◽  
Clinical Appearance ◽  
Mca Aneurysm

Abstract Four women, aged 39 to 46 years, were urgently admitted to our neurosurgical unit after strokes. On admission, all appeared moribund, presenting with deep coma, pupils bilaterally dilated and fixed, decerebrate posture, and markedly abnormal respiratory patterns. Computed tomography revealed subarachnoid hemorrhage with an associated large intracerebral hematoma and pronounced shift of midline structures in all four cases. Because of the clinical appearance, the patients were given urea and were operated without preceding angiography. The origin of the hemorrhage was identified as a middle cerebral artery (MCA) bifurcation berry aneurysm in one patient and giant MCA aneurysms in the other three. The hematomas were evacuated, and the aneurysms were occluded. All four patients received intravenous nimodipine, none showed any sign of delayed ischemic deterioration, and all regained full consciousness within a few days. One patient died 3 weeks later from a pulmonary embolus. Three patients are presently at home with moderate focal neurological deficits and moderate to marked cognitive impairment. The psychosocial readjustment was very good in a patient with a left giant aneurysm, satisfactory in a patient with a right giant aneurysm, and unsatisfactory in a patient with a right berry aneurysm. The indications, ethical considerations, and technical aspects of operating on seemingly moribund patients who probably harbor a ruptured MCA aneurysm are discussed.

scholarly journals Ruptured giant aneurysm of a cortical middle cerebral artery: A case report

2021 ◽  
Vol 12 ◽  
pp. 95
Author(s):  
Samer S. Hoz ◽  
Zaid Aljuboori ◽  
Sajaa A. Albanaa ◽  
Zahraa F. Al-Sharshahi ◽  
Mohammed A. Alrawi ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Giant Aneurysm ◽  
Neurological Deficits ◽  
Intracerebral Hematoma ◽  
Microsurgical Clipping ◽  
Level Of Consciousness ◽  
History Of ◽  
Posterior Parietal ◽  
Mca Aneurysm

Background: Aneurysms of the cortical branches of the middle cerebral artery (MCA) are rare. They usually are secondary to traumatic or infectious etiologies and are rarely idiopathic. The specific characteristics of idiopathic aneurysms in such location are not well defined in the literature. The authors report a rare case of a ruptured giant idiopathic cortical MCA aneurysm with review of the available literature on this clinical entity. Case Description: A 24-year-old female presented with headache, disturbed level of consciousness, and right-sided weakness. Imaging studies showed a left frontoparietal intracerebral hematoma and a giant saccular aneurysm in the posterior parietal cortical branch of the MCA. The patient had no history of head trauma or active infection; therefore, the aneurysm was considered idiopathic. A microsurgical clipping of the aneurysm with evacuation of the hematoma was performed. There were no surgical complications, and the patient achieved a good outcome modified Rankin Scale of 1 with no neurological deficits. Conclusion: Idiopathic aneurysms of the cortical branches of the MCA are rare, and usually present with intraparenchymal hemorrhage due to rupture. There is no clear consensus regarding the optimal management strategy. This case shows that timely management can lead to good outcomes.

Combination Superficial Temporal Artery-Middle Cerebral Artery Bypass and M2–M2 Reanastomosis With Trapping of a Stented Distal Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video

2018 ◽  
Vol 15 (5) ◽  
pp. E67-E68 ◽  
Author(s):  
Jan-Karl Burkhardt ◽  
Sonia Yousef ◽  
Halima Tabani ◽  
Arnau Benet ◽  
Roberto Rodriguez Rubio ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Artery Aneurysm ◽  
Temporal Artery ◽  
Sylvian Fissure ◽  
Neurological Deficits ◽  
Bypass Patency ◽  
Mca Aneurysm ◽  
Distal Middle Cerebral Artery

Abstract Distal middle cerebral artery (MCA) aneurysms often have non-saccular morphology and cannot be clipped, requiring revascularization and trapping instead. Combination bypasses are needed when 2 arteries exit the aneurysm, and extracranial–intracranial and intracranial–intracranial bypasses can be used. This video demonstrates a combination bypass used to treat a previously stented distal MCA aneurysm with both a superficial temporal artery (STA)-to-MCA bypass and an M2-to-M2 reanastomosis. This 56-yr-old man presented with distal left-sided MCA aneurysm 2 years earlier and attempted stent-assisted coiling was aborted after the aneurysm was perforated with stenting alone. Follow-up angiography demonstrated progressive aneurysm enlargement, and he was referred for surgery. The patient consented for the procedure and a pterional craniotomy extended posteriorly exposed the distal Sylvian fissure and efferent M4-cortical arteries. After splitting the Sylvian fissure, the “flash fluorescence” technique with indocyanine green (ICG) videoangiography identified an M4 recipient artery from the deeper of 2 exiting branches for STA–MCA bypass.1 The aneurysm was then trapped, and inflow and the more superficial outflow arteries were anastomosed end to end (M2–M2 in-situ bypass). A platelet plug that developed at the reanastomosis site was broken apart with mechanical manipulation, and ICG videoangiography demonstrated patency of both bypasses. The patient recovered without any neurological deficits, and postoperative computed tomography angiography confirmed bypass patency. Combination bypasses are needed when unclippable bifurcation aneurysms require revascularization. Careful intraoperative evaluation of patency of the bypass is imperative and helps identifying and addressing any potential early bypass occlusion.

scholarly journals Case Report: Ruptured Middle Cerebral Artery Aneurysm With Intrasylvian Hematoma Successfully Treated by Coil Embolization and Minimally Invasive Puncture and Drainage

2021 ◽  
Vol 12 ◽  
Author(s):  
Zhen Li ◽  
Quan Hu ◽  
Li Zhao ◽  
Huayun Huang ◽  
Shizhong Zhang ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Coil Embolization ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Artery Aneurysm ◽  
Intracerebral Hematoma ◽  
Intracranial Hematomas ◽  
Mca Aneurysm ◽  
Poor Outcomes

Up to one-third (12–35%) of patients with aneurysmal subarachnoid hemorrhage experience intracerebral hematoma. Ruptured middle cerebral artery (MCA) aneurysm with hematoma is usually accompanied by progressive cerebral swelling with poor outcomes; however, it can be successfully treated by coil embolization and minimally invasive puncture and drainage. From February 2012 to March 2019, six surgeries for ruptured MCA aneurysms with intrasylvian hematoma were performed at our clinic. All patients had intracranial hematomas of <30 ml and GCS scores >8. The patients were treated by coil embolization and minimally invasive puncture and drainage. The aneurysms in all patients were completely embolized and the hematomas were mostly removed by minimally invasive puncture. The Glasgow outcome scale (GOS) scores of all patients were more than 4 at discharge when they discharged. Coil embolization and minimally invasive puncture and drainage are viable treatments for ruptured MCA aneurysms with hematomas, especially if the patient is too old, in a complicated state to undergo craniotomy, is unwilling to undergo craniotomy, or is at a greater risk of bleeding 3 days after surgery.

Rupture of a Previously Unruptured Giant Middle Cerebral Artery Aneurysm after Extracranial-Intracranial Bypass Surgery

Neurosurgery ◽  
1982 ◽  
Vol 10 (5) ◽  
pp. 600-603 ◽  
Author(s):  
R. Michael Scott ◽  
Hsiu-Chih Liu ◽  
Robert Yuan ◽  
Lester Adelman
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Artery Aneurysm ◽  
Giant Aneurysm ◽  
Aneurysm Surgery ◽  
Middle Cerebral Artery Aneurysm ◽  
Fatal Hemorrhage ◽  
Cerebral Artery Aneurysm ◽  
Direct Attack

Abstract The fatal rupture of a previously unruptured giant middle cerebral artery aneurysm occurred 13 days after an extracranial-intracranial bypass had been carried out, before definitive aneurysm surgery. Alterations in blood flow adjacent to the aneurysm after the bypass may have led to the fatal hemorrhage. After a preliminary extracranial-intracranial bypass procedure, there should be no undue delay in the direct attack on a giant aneurysm, regardless of its mode of presentation.

RUPTURED ANEURYSM AT THE PERFORATING ARTERY SUPPLYING THE INSULA

Neurosurgery ◽  
2009 ◽  
Vol 65 (1) ◽  
pp. E206-E207 ◽  
Author(s):  
Servet Inci ◽  
Atila Akbay ◽  
Burcu Hazer ◽  
Kivilcim Yavuz ◽  
Tuncalp Ozgen
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Clinical Presentation ◽  
Artery Aneurysm ◽  
Intracerebral Hematoma ◽  
Aged Patients ◽  
Perforating Artery ◽  
Proximal Middle Cerebral Artery ◽  
Small Aneurysm

Abstract OBJECTIVE Aneurysms originating from perforating branches of the middle cerebral artery are quite rare. Most of them arise from the lenticulostriate arteries, frequently located within the basal ganglia. We report a perforating artery aneurysm that was entirely embedded within the limen insulae. CLINICAL PRESENTATION A 41-year-old man presented with an insular hematoma without subarachnoid hemorrhage caused by rupture of a small aneurysm on a perforating artery of the proximal middle cerebral artery supplying the insula. INTERVENTION This rare aneurysm was resected via the transsylvian-insular approach. CONCLUSION Although very rare, perforating artery aneurysms should be considered in young or middle-aged patients with an atypical intracerebral hematoma. This report discusses radiological and surgical characteristics of this unusual aneurysm.

scholarly journals Orbitozygomatic Craniotomy for Clipping a Complex Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (2) ◽  
pp. E33-E33
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Sylvian Fissure ◽  
Parent Artery ◽  
Parent Vessel ◽  
Institutional Review ◽  
Vessel Patency ◽  
Mca Aneurysm

Abstract Middle cerebral artery (MCA) aneurysms pose a surgical challenge because of the large caliber of the parent artery and the common need to dissect the sylvian fissure to permit access to the proximal and distal control. The neck of the aneurysm should be generously dissected to permit visualization of any adjacent lenticulostriate perforators. This patient demonstrated a left-sided wide-necked bilobed MCA aneurysm at the M1 bifurcation. The aneurysm was approached using a left orbitozygomatic craniotomy with distal sylvian fissure dissection. A single curved clip was applied for aneurysm occlusion, and postoperative angiography demonstrated aneurysm obliteration with parent vessel patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals A novel treatment of a patient with a giant ruptured middle cerebral artery aneurysm by acute coiling followed by scheduled Pipeline flex placement

2020 ◽  
Vol 33 (6) ◽  
pp. 517-519
Author(s):  
Shikai Liang ◽  
Ren Yuan ◽  
Xianli Lv
Keyword(s):  
Middle Cerebral Artery ◽  
Acute Phase ◽  
Cerebral Artery ◽  
Artery Aneurysm ◽  
Aneurysm Rupture ◽  
Flow Diversion ◽  
Neurological Deficits ◽  
Middle Cerebral Artery Aneurysm ◽  
Cerebral Artery Aneurysm

Objective Flow diversion in the acute phase of aneurysm rupture or giant aneurysm is limited by the need for dual antiplatelet therapy and the risk of delayed aneurysm rupture. Here, the authors report a scheduled flow-diversion concept for the endovascular treatment of a giant intra-dural aneurysm. Methods A 54-year-old female patient with a ruptured giant middle cerebral artery aneurysm underwent coiling in the acute phase following 1-month scheduled Pipeline flex placement. Results The acutely ruptured giant middle cerebral artery aneurysm was treated by flow diversion scheduled at 1 month after conventional coiling. The patient tolerated this treatment strategy well without any neurological deficits after the procedure and during the 3-month follow-up. The aneurysm showed nearly complete obliteration on 3-month follow-up angiogram, and a 6- to 12-month follow-up was scheduled. Conclusions This strategy may be considered as an option in patients presenting with ruptured or unruptured giant intra-dural aneurysms.

Ruptured distal middle cerebral artery aneurysm

2004 ◽  
Vol 100 (3) ◽  
pp. 384-388 ◽  
Author(s):  
Tetsuyoshi Horiuchi ◽  
Yuichiro Tanaka ◽  
Hisayoshi Takasawa ◽  
Takahiro Murata ◽  
Takehiro Yako ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Aneurysm ◽  
University Hospital ◽  
Content Type ◽  
Mca Aneurysm ◽  
Cerebral Artery Aneurysm ◽  
Ruptured Intracranial Aneurysms ◽  
Distal Middle Cerebral Artery ◽  
Fine Print

Object. Ruptured distal middle cerebral artery (MCA) aneurysms are uncommon, and their clinical and radiological features are poorly understood. To clarify characteristics of these lesions, the authors undertook a retrospective analysis of nine patients with ruptured distal MCA aneurysms. Methods. The medical records of patients who underwent surgical repair of ruptured intracranial aneurysms between 1988 and 2002 at Shinshu University Hospital and its affiliated hospitals were retrospectively evaluated. The authors found only nine patients with a ruptured distal MCA aneurysm, and their clinical, neuroimaging, and intraoperative findings were evaluated. Conclusions. This study of nine patients with distal MCA aneurysms is the largest series to date. Eight lesions were saccular aneurysms that were clipped and the remaining one was a mycotic aneurysm that was trapped. Eight of the nine patients suffered cerebral hematomas with subarachnoid hemorrhage. All patients had good outcomes after obliteration of their aneurysm, although their preoperative condition was not good.

Relationship between middle cerebral parent artery asymmetry and middle cerebral artery aneurysm rupture risk factors

2020 ◽  
Vol 132 (4) ◽  
pp. 1174-1181 ◽  
Author(s):  
Yifei Duan ◽  
Carlito Lagman ◽  
Raleigh Ems ◽  
Nicholas C. Bambakidis
Keyword(s):  
High Risk ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Aneurysm ◽  
Vascular Pathology ◽  
Control Group ◽  
Parent Artery ◽  
Primary Control ◽  
Aneurysm Formation ◽  
Mca Aneurysm

OBJECTIVEThe exact pathophysiological mechanisms underlying cerebral aneurysm formation remain unclear. Asymmetrical local vascular geometry may play a role in aneurysm formation and progression. The object of this study was to investigate the association between the geometric asymmetry of the middle cerebral artery (MCA) and the presence of MCA aneurysms and associated high-risk features.METHODSUsing a retrospective case-control study design, the authors examined MCA anatomy in all patients who had been diagnosed with an MCA aneurysm in the period from 2008 to 2017 at the University Hospitals Cleveland Medical Center. Geometric features of the MCA ipsilateral to MCA aneurysms were compared with those of the unaffected contralateral side (secondary control group). Then, MCA geometry was compared between patients with MCA aneurysms and patients who had undergone CTA for suspected vascular pathology but were ultimately found to have normal intracranial vasculature (primary control group). Parent vessel and aneurysm morphological parameters were measured, calculated, and compared between case and control groups. Associations between geometric parameters and high-risk aneurysm features were identified.RESULTSThe authors included 247 patients (158 cases and 89 controls) in the study. The aneurysm study group consisted of significantly more women and smokers than the primary control group. Patients with MCA bifurcation aneurysms had lower parent artery inflow angles (p = 0.01), lower parent artery tortuosity (p < 0.01), longer parent artery total length (p = 0.03), and a significantly greater length difference between ipsilateral and contralateral prebifurcation MCAs (p < 0.01) than those in primary controls. Type 2 MCA aneurysms (n = 89) were more likely to be associated with dome irregularity or a daughter sac and were more likely to have a higher cumulative total of high-risk features than type 1 MCA aneurysms (n = 69).CONCLUSIONSData in this study demonstrated that a greater degree of parent artery asymmetry for MCA aneurysms is associated with high-risk features. The authors also found that the presence of a long and less tortuous parent artery upstream of an MCA aneurysm is a common phenotype that is associated with a higher risk profile. The aneurysm parameters are easily measurable and are novel radiographic biomarkers for aneurysm risk assessment.

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