Contralateral Clipping of Middle Cerebral Artery Aneurysms

Abstract BACKGROUND: Contralateral clipping of middle cerebral artery (MCA) aneurysms seems dangerous and ill advised but could become an important technique because of the prevalence of MCA aneurysms, the limitations of endovascular therapy, and increasing interest in less invasive techniques. OBJECTIVE: To define patient selection, surgical technique, and results with contralateral MCA aneurysm clipping. METHODS: Forty-two patients with bilateral MCA aneurysms were treated either in 1 stage with a single craniotomy and contralateral aneurysm clipping (group 1, 11 patients) or in 2 stages with bilateral craniotomy (group 2, 31 patients). Surgical technique consisted of ipsilateral sylvian fissure split, subfrontal dissection, contralateral sylvian fissure split, mobilization of medial orbital gyrus, and contralateral aneurysm clipping. RESULTS: Group 1 patients were older than group 2 patients (60.3 vs 55.4 years, respectively). Clinical presentation with subarachnoid hemorrhage was less common in group 1. Nine group 1 patients (82%) had left-sided craniotomies, and the ipsilateral aneurysm was larger than the contralateral aneurysm. All aneurysms were clipped without intraoperative complications (136 aneurysms). Mean neurosurgical charges were decreased by contralateral MCA aneurysm clipping: $39 297 in group 1 vs $57 977 in group 2. CONCLUSION: Contralateral MCA aneurysm clipping can be viewed as an extreme microsurgical technique or as a less invasive technique that spares patients a second craniotomy in the management of bilateral aneurysms. This technique is acceptable in selected patients with contralateral aneurysms that are unruptured, have simple necks, project inferiorly or anteriorly, are associated with short M1 segments, and reside in older patients with sylvian fissures widened by brain atrophy.

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The Morphology of Somatosensory Evoked Potentials During Middle Cerebral Artery Aneurysm Clipping (MoSAC): A Pilot Study

Clinical EEG and Neuroscience ◽

10.1177/1550059419874942 ◽

2019 ◽

Vol 51 (2) ◽

pp. 130-136

Author(s):

Franca Tecchio ◽

Federico Cecconi ◽

Elisabetta Colamartino ◽

Matteo Padalino ◽

Luca Valci ◽

...

Keyword(s):

Blood Flow ◽

Pilot Study ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Small Sample ◽

Flow Reduction ◽

Aneurysm Clipping ◽

Blood Flow Reduction ◽

Mca Aneurysm ◽

Sep Monitoring

Somatosensory evoked potential (SEP) monitoring is a standard tool during clipping of aneurysms of the middle cerebral artery (MCA), and the parameter used to detect a state of cortical ischemia is amplitude. We think that the sensitivity of SEP can however be improved by using other parameters. Our study moves in this direction via SEP morphology. In this pilot preliminary study, involving a small sample without postoperative neurological deficit, we aimed at investigating the value of SEP morphology (in the 15- to 35-ms time frame), in comparison with SEP amplitude (N20 peak-to-peak), as a measure of sensitivity to blood flow reduction. The changes in the SEP morphology of 16 patients undergoing clipping of an unruptured MCA aneurysm was studied. We applied the Morph-Fréchet index for each recorded SEP (at 30-second intervals), quantifying the pattern shape change with regard to the average SEP recorded after dura opening (baseline). We also compared 3 measurements of the SEP morphology, without and with GARCH-derived filter. Filtered Morph-Fréchet never exceeded the individual’s “normality” range in baseline but did so in 81% of the risk phase on average across the 16 subjects, which is more than that for amplitude (36%, P = .002). This pilot study indicates that a measurement derived from the networking nature of the brain was sensitive to blood flow reduction. The SEP morphology approach promises to improve SEP monitoring sensitivity during clipping of unruptured MCA aneurysms. New and Noteworthy. The higher sensitivity to blood flow reduction of SEP morphology than amplitude promises to improve the effectiveness of intraoperative monitoring during MCA aneurysm clipping procedures.

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Effects of Sufentanil on Cerebral Hemodynamics and Intracranial Pressure in Patients with Brain Injury

Anesthesiology ◽

10.1097/00000542-199510000-00011 ◽

1995 ◽

Vol 83 (4) ◽

pp. 721-726. ◽

Cited By ~ 79

Author(s):

Christian Werner ◽

Eberhard Kochs ◽

Hanswerner Bause ◽

William E. Hoffman ◽

Jochen Schulte am Esch

Keyword(s):

Blood Flow ◽

Middle Cerebral Artery ◽

Flow Velocity ◽

Cerebral Artery ◽

Blood Flow Velocity ◽

Artery Blood Flow ◽

Arterial Blood ◽

Norepinephrine Infusion ◽

Group 2 ◽

Group 1

Background The current study investigates the effects of sufentanil on cerebral blood flow velocity and intracranial pressure (ICP) in 30 patients with intracranial hypertension after severe brain trauma (Glasgow coma scale < 6). Methods Mechanical ventilation (FIO2 0.25-0.4) was adjusted to maintain arterial carbon dioxide tensions of 28-30 mmHg. Continuous infusion of midazolam (200 micrograms/kg/h intravenous) and fentanyl (2 micrograms/kg/h intravenous) was used for sedation. Mean arterial blood pressure (MAP, mmHg) was adjusted using norepinephrine infusion (1-5 micrograms/min). Mean blood flow velocity (Vmean, cm/s) was measured in the middle cerebral artery using a 2-MHz transcranial Doppler sonography system. ICP (mmHg) was measured using an epidural probe. After baseline measurements, a bolus of 3 micrograms/kg sufentanil was injected, and all parameters were continuously recorded for 30 min. The patients were assigned retrospectively to the following groups according to their blood pressure responses to sufentanil: group 1, MAP decrease of less than 10 mmHg, and group 2, MAP decrease of more than 10 mmHg. Results Heart rate, arterial blood gases, and esophageal temperature did not change over time in all patients. In 18 patients, MAP did not decrease after sufentanil (group 1). In 12 patients, sufentanil decreased MAP > 10 mmHg from baseline despite norepinephrine infusion (group 2). ICP was constant in patients with maintained MAP (group 1) but was significantly increased in patients with decreased MAP. Vmean did not change with sufentanil injection regardless of changes in MAP. Conclusions The current data show that sufentanil (3 micrograms/kg intravenous) has no significant effect on middle cerebral artery blood flow velocity and ICP in patients with brain injury, intracranial hypertension, and controlled MAP. However, transient increases in ICP without changes in middle cerebral artery blood flow velocity may occur concomitant with decreases in MAP. This suggests that increases in ICP seen with sufentanil may be due to autoregulatory decreases in cerebral vascular resistance secondary to systemic hypotension.

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

Operative Neurosurgery ◽

10.1093/ons/opz314 ◽

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.

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Clipping and STA-MCA bypass for unruptured AcomA aneurysm associated with unilateral MCA occlusion

Neurosurgical FOCUS ◽

10.3171/2015.v1.focus14469 ◽

2015 ◽

Vol 38 (videosuppl1) ◽

pp. Video2 ◽

Cited By ~ 1

Author(s):

Tomohiro Inoue ◽

Hiroki Yoshida ◽

Akira Tamura ◽

Isamu Saito

Keyword(s):

Surgical Technique ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Sylvian Fissure ◽

Anterior Communicating Artery ◽

Mca Occlusion ◽

Interhemispheric Fissure ◽

Good Exposure

The authors show a surgical technique of clipping in conjunction with superficial temporal artery (STA)–middle cerebral artery (MCA) bypass to treat unruptured anterior communicating artery (AcomA) aneurysm associated with unilateral MCA occlusion. First, through MCA occlusion side, fronto-temporal craniotomy, extra-dural drilling of lesser sphenoid wing, and followed by wide exposure of Sylvian fissure, STA–MCA bypass was performed. Then, through trans-Sylvian, fronto-basal, and lateral trajectory, interhemispheric fissure was dissected from the base, which enabled good exposure and clipping of high positioned AcomA aneurysm.The video can be found here: http://youtu.be/GWItnRSs3m4.

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Image-Guided Surgery for Treatment of Unruptured Middle Cerebral Artery Aneurysms

Operative Neurosurgery ◽

10.1227/01.neu.0000303979.88880.06 ◽

2007 ◽

Vol 61 (suppl_5) ◽

pp. ONS266-ONS272 ◽

Cited By ~ 9

Author(s):

Young-Je Son ◽

Dae Hee Han ◽

Jeong Eun Kim

Keyword(s):

Minimally Invasive ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Image Guidance ◽

Invasive Technique ◽

Surgical Clipping ◽

Guided Surgery ◽

Image Guided ◽

Mca Aneurysm ◽

Middle Cerebral Artery Aneurysms

Abstract Objective: Direct surgical clipping appears to be an efficient means for managing unruptured middle cerebral artery (MCA) aneurysms, owing to several angioanatomic features. Here, we present a minimally invasive technique that uses navigation guidance for the treatment of unruptured MCA aneurysms. Methods: Between July of 2003 and June of 2005, we used image-guidance navigation to operate on 24 patients who were diagnosed with unruptured MCA aneurysm. Five men and 19 women were included in the study, and their ages ranged from 43 to 70 years (mean, 58 yr). We predetermined the transsylvian trajectory toward the aneurysm and planned a tailored craniotomy for each patient. Results: All aneurysms were readily identified and successfully clipped via craniotomies of less than 3 cm in diameter. We experienced no surgical complications, and each patient had an uneventful postoperative course. Conclusion: With the aid of navigation, we were able to easily locate MCA aneurysms and perform minimally invasive surgeries such as mini-craniotomies, tailored sylvian dissections, and successful clippings of unruptured MCA aneurysms. In addition, we obtained satisfactory cosmetic results.

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Cerebral blood flow of children with vasovagal syncope

Cardiology in the Young ◽

10.1017/s1047951113002059 ◽

2014 ◽

Vol 25 (2) ◽

pp. 267-273 ◽

Cited By ~ 4

Author(s):

Barsan Tugba ◽

Kilic Zubeyir ◽

Uzuner Nevzat ◽

Yildirim Ali ◽

Ucar Birsen ◽

...

Keyword(s):

Blood Flow ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Flow Rate ◽

Vasovagal Syncope ◽

Blood Flow Rate ◽

Tilt Test ◽

Control Group ◽

Group 2 ◽

Group 1

AbstractIntroduction: We aimed to evaluate changes in the cerebral blood supply in children during vasovagal syncope and to clarify the diagnostic value of transcranial Doppler for vasovagal syncope. Materials and methods: Patients were divided into three groups. Group 1 consisted of 31 patients who were symptomatic and whose head-up tilt test was positive. Group 2 comprised 21 patients who were symptomatic but whose tilt test was negative. Group 3 included 22 healthy children. For the diagnosis of vasovagal syncope, the tilt test was applied. For the subjects of the patient and control groups, the tilt test was repeated. The flow rates of bilateral middle cerebral arteries were continuously and simultaneously recorded with temporal window transcranial Doppler. Results: There were no statistically significant differences between the three groups with respect to age and gender distribution (p>0.05). When the bed was at an upright position, the maximum blood flow rate of the right middle cerebral artery was lower in Group 1 than in Group 2, although the decrease was more significant in comparison to the healthy control group (p<0.05). The minimum blood flow rate of the right middle cerebral artery was lower in Group 1 than the Group 2, although the decrease was more significant in comparison with the healthy control group (p<0.05). The maximum blood flow rate of the left middle cerebral artery was significantly lower in Group 1 than in the control group (p<0.05). Conclusion: Minimum and maximum blood flow rates are significantly decreased in patients tilt test (+) patients with vasovagal syncope during orthostatic stress.

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Evaluation of fetal condition in uncomplicated pregnancies at 40 weeks and beyond by calculation of amniotic fluid indexes and Doppler in the middle cerebral artery.

10.22541/au.161012470.09423216/v1 ◽

2021 ◽

Author(s):

elvira semenova ◽

Nikolai Rukhliada ◽

Olga Klicenko

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Inclusion Criteria ◽

Trigger Level ◽

Hypoxic Brain Damage ◽

Emergency Cesarean ◽

Hypoxic Brain ◽

Group 3 ◽

Group 2 ◽

Group 1

Objective. The aim of our data is to reveal the method of prognosis abnormal perinatal outcome, using combination US and Doppler results in uncomplicated pregnancies at 40 weeks and beyond. Design.1020 uncomplicated pregnant women at 40 weeks and beyond were examined 48 hours before delivery. We analyzed fetus’s condition during labor and just after. Setting. According these dates all women were divided into 3 groups after amniotic index(AI)and pulsatility indices(PI) in the middle cerebral artery(MCA). Population.260 women were included in the study because they met the inclusion criteria. Methods.All women were divided into 3 groups (group 1 - PI>0.835, any value of AI, group 2-AI >85, PI ≤ 0.835, group 3- AI ≤ 85 and PI ≤ 0.835).We analyzed fetus’s condition during labor and just after delivery (Apgar score <=7 and >7 on the 1st minute). Result. We’ve got trigger level for pulsatility index (PI) as 0.835, if we had PI less than that threshold cases of emergency cesarean section increases in 2,12 times, if PI less than 0,835 in combination with Amniotic Index(AI) 85 and less in 5,28 times. If PI =<0,835 risk of newborns having Apgar 7 and less increases in 1,18, but in combination with AI =<85 in 4,72 times. Conclusion. In results we found out the following data: low PI in the MCA may be parameter which cans prognoses fetus distress. Combination of PI reduce with low AI increases its specific and can use in practical ways to avoid hypoxic brain damage during labor.

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Induction of Spreading Depression in the Ischemic Hemisphere following Experimental Middle Cerebral Artery Occlusion: Effect on Infarct Morphology

Journal of Cerebral Blood Flow & Metabolism ◽

10.1097/00004647-199603000-00004 ◽

1996 ◽

Vol 16 (2) ◽

pp. 202-213 ◽

Cited By ~ 196

Author(s):

Tobias Back ◽

Myron D. Ginsberg ◽

W. Dalton Dietrich ◽

Brant D. Watson

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Spreading Depression ◽

Ischemic Injury ◽

Artery Occlusion ◽

Ischemic Penumbra ◽

Mca Occlusion ◽

Group 3 ◽

Group 2 ◽

Group 1

This study was undertaken to test whether transient depolarizations occurring in periinfarct regions are important in contributing to infarct spread and maturation. Following middle cerebral artery (MCA) occlusion we stimulated the ischemic penumbra with recurrent waves of spreading depression (SD) and correlated the histopathological changes with the electrophysiological recordings. Halothane-anesthetized, artificially ventilated Sprague–Dawley rats underwent repetitive stimulation of SD in intact brain (Group 1; n = 8) or photothrombotic MCA occlusion coupled with ipsilateral common carotid artery occlusion (Groups 2 and 3, n = 9 each). The electroencephalogram and direct current (DC) potential were recorded for 3 h in the parietal cortex, which represented the periinfarct border zone in ischemic rats. In Group 2, only spontaneously occurring negative DC shifts occurred; in Group 3, the (nonischemic) frontal pole of the ischemic hemisphere was electrically stimulated to increase the frequency of periinfarct DC shifts. Animals underwent perfusion-fixation 24 h later, and volumes of complete infarction and scattered neuronal injury (“incomplete infarction”) were assessed on stained coronal sections by quantitative planimetry. Electrical induction of SD in Group 1 did not cause morphological injury. During the initial 3 h following MCA occlusion, the number of spontaneous periinfarct depolarizations in Group 2 (7.0 ±1.5 DC shifts) was doubled in Group 3 by frontal current application (13.4 ± 2.7 DC shifts; p < 0.001). The duration as well as the integrated negative amplitude of DC shifts over time were significantly greater in Group 3 than in Group 2 rats (duration, 5.7 ± 3.8 vs. 4.1 ± 2.5 min; p < 0.05). Histopathological examination disclosed well-defined areas of pannecrosis surrounded by a cortical rim exhibiting selectively damaged acidophilic neurons and astrocytic swelling in otherwise normal-appearing brain. Induction of SD in the ischemic hemisphere led to a significant increase in the volume of incomplete infarction (19.0 ± 6.1 mm3 in Group 3 vs. 10.3 ± 5.1 mm3 in Group 2; p < 0.01) and of total ischemic injury (100.7 ± 41.0 mm3 in Group 3 vs. 66.5 ± 24.7 mm3 in Group 2; p < 0.05). The integrated magnitude of DC negativity per experiment correlated significantly with the volume of total ischemic injury ( r = 0.780, p < 0.0001). Thus, induction of SD in the ischemic hemisphere accentuated the development of scattered neuronal injury and increased the volume of total ischemic injury. This observation may be explained by the fact that, with limited perfusion reserve, periinfarct depolarizations are associated with episodic energy failure in the acute ischemic penumbra.

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M2/M2 Side-to-Side Rescue Anastomosis for Accidental M2 Trunk Occlusion during Middle Cerebral Artery Aneurysm Clipping: Technical Note

Neurosurgery ◽

10.1097/00006123-200109000-00041 ◽

2001 ◽

Vol 49 (3) ◽

pp. 743-748 ◽

Cited By ~ 1

Author(s):

Hans-Jakob Steiger ◽

Seiro Ito ◽

Robert Schmid-Elsässer ◽

Eberhard Uhl

Keyword(s):

Intracerebral Hemorrhage ◽

Middle Cerebral Artery ◽

Digital Subtraction Angiography ◽

Cerebral Artery ◽

Artery Aneurysm ◽

Maximum Diameter ◽

Digital Subtraction ◽

Emergency Procedure ◽

Aneurysm Clipping ◽

Mca Aneurysm

Abstract OBJECTIVE A technically feasible and rapid technique for revascularizing the main branches of the middle cerebral artery (MCA) is described. This technique is applied mainly when clipping of an MCA aneurysm is complicated and occlusion of the origin of an MCA main branch results. METHODS M2/M2 side-to-side anastomosis was applied in two patients in whom unplanned M2 occlusion occurred during the course of complicated MCA aneurysm clipping. The first patient underwent an emergency procedure after temporoparietal intracerebral hemorrhage. Unilateral mydriasis precluded preoperative angiographic workup, and a complex large MCA aneurysm was found as the source of hemorrhage. Shaping of the aneurysm neck by bipolar coagulation and clipping resulted in accidental occlusion of the superior trunk, and patency could not be regained despite multiple clip corrections. The second patient had an unruptured multilobulated aneurysm 8 mm in maximum diameter. Continuity of the inferior trunk was lost during clipping because of a tear at the origin. In both instances, side-to-side anastomosis was placed approximately 15 mm from the bifurcation, where the MCA main trunks ran side by side for a length of approximately 5 mm. RESULTS After intracerebral hemorrhage, the first patient recovered to a level of moderate disability within 2 months. Substantial hemiparesis and expressive dysphasia remained as sequelae of the intracerebral hemorrhage. Digital subtraction angiography 2 months after the emergency procedure confirmed patency of the side-to-side anastomosis. The second patient was neurologically intact after recovery from anesthesia. Before discharge from the hospital on postoperative Day 8, digital subtraction angiography confirmed patency of the anastomosis. CONCLUSION The MCA main branches usually run in close proximity for a short segment at the bottleneck entrance to the insular cistern. M2/M2 side-to-side anastomosis at this site is a rapid and feasible mode of revascularization of an M2 trunk accidentally occluded during complicated MCA aneurysm clipping.

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Surgical Management of Ruptured Middle Cerebral Artery Aneurysms With Large Intraparenchymal or Sylvian Fissure Hematomas

Neurosurgery ◽

10.1227/neu.0000000000000596 ◽

2015 ◽

Vol 76 (3) ◽

pp. 258-264 ◽

Cited By ~ 19

Author(s):

Christopher J. Stapleton ◽

Brian P. Walcott ◽

Matthew R. Fusco ◽

William E. Butler ◽

Ajith J. Thomas ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Treatment Modality ◽

Aneurysm Rupture ◽

Sylvian Fissure ◽

Hematoma Evacuation ◽

Aneurysm Clipping ◽

Angiographic Vasospasm ◽

Fisher Grade ◽

Intracranial Hematomas

Abstract BACKGROUND: Craniotomy for hematoma evacuation and aneurysm clipping is the treatment modality of choice for ruptured middle cerebral artery (MCA) aneurysms with intracranial hematomas. Recent literature suggests that endovascular coil embolization followed by hematoma evacuation can be an acceptable alternative. OBJECTIVE: To determine neurological outcomes in patients with ruptured MCA aneurysms and intraparenchymal or sylvian fissure hematomas. METHODS: The records of 49 patients with ruptured MCA aneurysms with large intracranial hematomas treated with hematoma evacuation and aneurysm clipping between January 2000 and December 2013 were retrospectively reviewed. RESULTS: Within this cohort, 35 patients (71.4%) were Hunt and Hess grade IV or V on presentation. The mean hematoma volume was 100.4 ± 77.2 mL. Craniectomy was performed in 40 patients (81.6%). Angiographic vasospasm developed in 15 patients (30.6%). The in-hospital mortality rate was 28.6% (14 patients). At a mean of 25.3 ± 34.0 months follow-up, a good outcome (modified Rankin Scale [mRS] score 0–3) was observed in 18 patients (36.7%). Significant factors associated with poor outcome or death (mRS scores of 4–6) included increasing age (P < .01), increasing Hunt and Hess grade (P = .03), increasing modified Fisher grade (P = .01), presence of intraventricular hemorrhage (P < .01), decreasing percentage of hematoma evacuation (P < .05), need for craniectomy (P <. 01), need for external ventricular drainage (P = .04), and angiographic vasospasm (P = .02). CONCLUSION: MCA aneurysm rupture with concomitant large intraparenchymal or sylvian fissure hematoma formation carries a grave prognosis. Simultaneous hematoma evacuation and aneurysm clipping with or without craniectomy can be an effective treatment modality.

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