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

2006 ◽  
Vol 59 (suppl_4) ◽  
pp. ONS-347-ONS-352 ◽  
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.

Sequential Coiling-Assisted Deployment of Flow Diverter for Treatment of Fusiform Middle Cerebral Artery Aneurysms

2017 ◽  
Vol 15 (2) ◽  
pp. E13-E18 ◽  
Author(s):  
Abdulrahman Y Alturki ◽  
Philip G R Schmalz ◽  
Christopher S Ogilvy ◽  
Ajith J Thomas
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Vascular Anatomy ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Anterior Circulation ◽  
Vertebrobasilar System ◽  
Middle Cerebral Artery Aneurysms ◽  
Vessel Reconstruction

Abstract BACKGROUND AND IMPORTANCE Fusiform intracranial aneurysms remain challenging lesions to treat. These aneurysms have historically required bypass procedures or clip remodeling constructs for cure. Recently, endovascular specialists have reported experience with flow diversion for complex fusiform aneurysms of the vertebrobasilar system, with mixed results. Vascular anatomy for anterior circulation fusiform aneurysms may make these lesions more amenable to flow diversion and embolization procedures; however, published experience with these techniques is lacking. In this report, we describe a sequential coiling-assisted deployment of flow diverter for the treatment of fusiform middle cerebral artery (MCA-M1) aneurysms in 2 cases, 1 presenting acutely with subarachnoid hemorrhage and another with progressive aneurysm enlargement. CLINICAL PRESENTATION Two patients, a 36-yr-old male presenting with subarachnoid hemorrhage and a 60-yr-old female presenting with aneurysm enlargement were treated for fusiform aneurysms of the M1 segment of the MCA using a sequential, partial deployment of coils and flow diverter through 2 microcatheters to facilitate mutual mechanical support for both coil and flow diverter (Pipeline Embolization Device; Medtronic Inc, Dublin, Ireland). Both patients achieved favorable outcomes and follow-up angiography demonstrated complete vessel reconstruction in both cases. CONCLUSION The treatment of complex, fusiform, large vessel aneurysms remains challenging. As experience with new endovascular technologies and techniques grows, these lesions may be treated safely with interventional methods. The technique of partial flow diverter deployment and stabilization with coils with sequential delivery of both devices using dual microcatheter was both safe and effective.

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

2017 ◽  
Vol 127 (3) ◽  
pp. 463-479 ◽  
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.

Coiling Versus Microsurgical Clipping in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis

Neurosurgery ◽  
2018 ◽  
Vol 83 (5) ◽  
pp. 879-889 ◽  
Author(s):  
Meshal Alreshidi ◽  
David J Cote ◽  
Hormuzdiyar H Dasenbrock ◽  
Michael Acosta ◽  
Anil Can ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Meta Analysis ◽  
Pooled Analysis ◽  
Endovascular Coiling ◽  
Neurological Outcomes ◽  
Microsurgical Clipping ◽  
Unruptured Intracranial Aneurysms ◽  
The Status ◽  
Middle Cerebral Artery Aneurysms

Abstract BACKGROUND Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo. OBJECTIVE To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis. METHODS A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed. RESULTS Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different. CONCLUSION This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

“Picket Fence” clipping technique for large and complex aneurysms

2015 ◽  
Vol 39 (videosuppl1) ◽  
pp. V17 ◽  
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.

Editorial. Clipping versus coiling for the treatment of middle cerebral artery aneurysms: which modality should be considered first?

2020 ◽  
Vol 133 (4) ◽  
pp. 1120-1123
Author(s):  
Tyler Scullen ◽  
Mansour Mathkour ◽  
John D. Nerva ◽  
Aaron S. Dumont ◽  
Peter S. Amenta
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Middle Cerebral Artery Aneurysms

scholarly journals Altered mental status with mirror giant middle cerebral artery aneurysms: A case report

2021 ◽  
pp. 101154
Author(s):  
Kamil W. Nowicki ◽  
Jasmine L. Hect ◽  
Nallamai Muthiah ◽  
Arka N. Mallela ◽  
Benjamin M. Zussman
Keyword(s):  
Case Report ◽  
Middle Cerebral Artery ◽  
Mental Status ◽  
Cerebral Artery ◽  
Altered Mental Status ◽  
Middle Cerebral Artery Aneurysms

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

ORL ◽  
2021 ◽  
pp. 1-9
Author(s):  
Ali Karadag ◽  
Baran Bozkurt ◽  
Kaan Yagmurlu ◽  
Ada Irmak Ozcan ◽  
Sean Moen ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Surgical Complications ◽  
Digital Camera ◽  
Head Rotation ◽  
Complex Aneurysms ◽  
Head Positioning ◽  
Supraorbital Approach ◽  
Lateral Supraorbital Approach ◽  
Head Positions

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.

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