scholarly journals Aplastic or twig-like middle cerebral artery harboring unruptured cerebral aneurysms treated by clipping and bypass surgery: illustrative case

2021 ◽  
Vol 2 (9) ◽  
Author(s):  
Ayako Takarada ◽  
Kiyoyuki Yanaka ◽  
Kuniyuki Onuma ◽  
Kazuhiro Nakamura ◽  
Nobuyuki Takahashi ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Treatment Method ◽  
Optimal Treatment ◽  
Illustrative Case ◽  
Unruptured Aneurysms ◽  
Aneurysm Clipping ◽  
Hemodynamic Stress ◽  
The Impact

BACKGROUND Aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a congenital MCA anomaly. It may present with symptoms of both hemorrhage and ischemia, similar to moyamoya disease, and hemodynamic stress may play an essential role in the development of symptoms in both clinical entities. The optimal treatment remains controversial in symptomatic patients with Ap/T-MCA. This report discussed the treatment method for a patient with Ap/T-MCA with unruptured aneurysms who presented with intraventricular hemorrhage (IVH) treated by aneurysm clipping and bypass surgery. OBSERVATIONS In a 46-year-old woman with a sudden headache, computed tomography showed left IVH. Magnetic resonance angiography showed a left MCA aneurysm and MCA trunk stenosis. Three-dimensional angiography demonstrated a plexiform arterial network and multiple aneurysms arising from the MCA and in the plexiform network, leading to the diagnosis of Ap/T-MCA harboring unruptured aneurysms. The patient was successfully treated by craniotomy with aneurysm clipping and bypass surgery to prevent further intracranial hemorrhages and/or aneurysm rupture. LESSONS Especially in cases such as Ap/T-MCA, in which hemodynamic stress has a significant effect, the optimal treatment method should be based on vascular morphology and the impact of hemodynamic stress.

scholarly journals Modeling of the Human Cerebral Collateral Circulation: Evaluation of the Impact on the Cerebral Perfusion in Case of Ischemic Stroke

2019 ◽  
Vol 5 (1) ◽  
pp. 533-536
Author(s):  
Lorena Krames ◽  
Rosa Daschner ◽  
Yannick Lutz ◽  
Axel Loewe ◽  
Olaf Dössel ◽  
...  
Keyword(s):  
Blood Flow ◽  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Collateral Circulation ◽  
Treatment Method ◽  
Developed Countries ◽  
Extended Model ◽  
Flow Through ◽  
The Impact

AbstractStroke is the third-most cause of death in developed countries. A new promising treatment method in case of an ischemic stroke is selective intracarotid blood cooling combined with mechanical artery recanalization. However, the control of the treatment requires invasive or MRI-assisted measurement of cerebral temperature. An auspicious alternative is the use of computational modeling. In this work, we extended an existing 1D hemodynamics model including the characteristics of the anterior, middle and posterior cerebral artery. Furthermore, seven ipsilateral anastomoses were additionally integrated for each hemisphere. A potential stenosis was placed into the M1 segment of the middle cerebral artery, due to the highest risk of occlusion there. The extended model was evaluated for various degrees of collateralization (“poor”, “partial” and “good”) and degrees of stenosis (0%, 50%, 75% and 99.9%). Moreover, cerebral autoregulation was considered in the model. The higher the degree of collateralization and the degree of stenosis, the higher was the blood flow through the collaterals. Hence, a patient with a good collateralization could compensate a higher degree of occlusion and potentially has a better outcome after an ischemic stroke. For a 99.9% stenosis, an increased summed mean blood flow through the collaterals of +97.7% was predicted in case of good collateralization. Consequently, the blood supply via the terminal branches of the middle cerebral artery could be compensated up to 44.4% to the physiological blood flow. In combination with a temperature model, our model of the cerebral collateral circulation can be used for tailored temperature prediction for patients to be treated with selective therapeutic hypothermia.

BYPASS SURGERY FOR COMPLEX BRAIN ANEURYSMS

Neurosurgery ◽  
2009 ◽  
Vol 65 (4) ◽  
pp. 670-683 ◽  
Author(s):  
Nader Sanai ◽  
Zsolt Zador ◽  
Michael T. Lawton
Keyword(s):  
Middle Cerebral Artery ◽  
Scale Score ◽  
Cerebral Artery ◽  
Glasgow Outcome Scale ◽  
Bypass Surgery ◽  
Unruptured Aneurysms ◽  
Bypass Patency ◽  
Cerebellar Artery ◽  
Brain Aneurysms

Abstract OBJECTIVE Bypass surgery for brain aneurysms is evolving from extracranial-intracranial (EC-IC) to intracranial-intracranial (IC-IC) bypasses that reanastomose parent arteries, revascularize efferent branches with in situ donor arteries or reimplantation, and reconstruct bifurcated anatomy with grafts that are entirely intracranial. We compared results with these newer IC-IC bypasses to conventional EC-IC bypasses. METHODS During a 10-year period, 82 patients underwent bypass surgery as part of their aneurysm management. A quarter of the patients presented with ruptured aneurysms and two-thirds presented with compressive symptoms from unruptured aneurysms. Most aneurysms (82%) had non-saccular morphology and 56% were giant sized. Common locations included the cavernous internal carotid artery (23%), middle cerebral artery (20%), and posteroinferior cerebellar artery (12%). RESULTS Forty-seven patients (57%) received EC-IC bypasses and 35 patients (43%) received IC-IC bypasses, including 9 in situ bypasses, 6 reimplantations, 11 reanastomoses, and 9 intracranial grafts. Aneurysm obliteration rates were comparable in EC-IC and IC-IC bypass groups (97.9% and 97.1%, respectively), as were bypass patency rates (94% and 89%, respectively). Three patients died (surgical mortality, 3.7%), and 4 patients were permanently worse as a result of bypass occlusions (neurological morbidity, 4.9%). At late follow-up (mean duration, 41 months), good outcomes (Glasgow Outcome Scale score 5 or 4) were measured in 68 patients (90%) overall, and were similar in EC-IC and IC-IC bypass groups (91% and 89%, respectively). Changes in Glasgow Outcome Scale score were slightly more favorable with IC-IC bypass (6% worse or dead after IC-IC bypass versus 14% with EC-IC bypass). CONCLUSION IC-IC bypasses compare favorably to EC-IC bypasses in terms of aneurysm obliteration rates, bypass patency rates, and neurological outcomes. IC-IC bypasses can be more technically challenging to perform, but they do not require harvest of extracranial donor arteries, spare patients a neck incision, shorten interposition grafts, are protected inside the cranium, use caliber-matched donor and recipient arteries, and are not associated with ischemic complications during temporary arterial occlusions. IC-IC bypass can replace conventional EC-IC bypass with more anatomic reconstructions for selected aneurysms involving the middle cerebral artery, posteroinferior cerebellar artery, anterior cerebral artery, and basilar apex.

scholarly journals Microsurgical clipping of middle cerebral artery aneurysms: preoperative planning using virtual reality to reduce procedure time

2021 ◽  
Vol 51 (2) ◽  
pp. E12
Author(s):  
Thomas C. Steineke ◽  
Daniela Barbery
Keyword(s):  
Virtual Reality ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Preoperative Planning ◽  
Control Group ◽  
Procedure Time ◽  
Aneurysm Clipping ◽  
Microsurgical Clipping ◽  
The Mean ◽  
The Impact

OBJECTIVE The authors sought to evaluate the impact of virtual reality (VR) applications for preoperative planning and rehearsal on the total procedure time of microsurgical clipping of middle cerebral artery (MCA) ruptured and unruptured aneurysms compared with standard surgical planning. METHODS A retrospective review of 21 patients from 2016 to 2019 was conducted to determine the impact on the procedure time of MCA aneurysm clipping after implementing VR for preoperative planning and rehearsal. The control group consisted of patients whose procedures were planned with standard CTA and DSA scans (n = 11). The VR group consisted of patients whose procedures were planned with a patient-specific 360° VR (360VR) model (n = 10). The 360VR model was rendered using CTA and DSA data when available. Each patient was analyzed and scored with a case complexity (CC) 5-point grading scale accounting for aneurysm size, incorporation of M2 branches, and aspect ratio, with 1 being the least complex and 5 being the most complex. The mean procedure times were compared between the VR group and the control group, as were the mean CC score between the groups. Comorbidities and aneurysm conduction (ruptured vs unruptured) were also taken into consideration for the comparison. RESULTS The mean CC scores for the control group and VR group were 2.45 ± 1.13 and 2.30 ± 0.48, respectively. CC was not significantly different between the two groups (p = 0.69). The mean procedure time was significantly lower for the VR group compared with the control group (247.80 minutes vs 328.27 minutes; p = 0.0115), particularly for the patients with a CC score of 2 (95% CI, p = 0.0064). A Charlson Comorbidity Index score was also calculated for each group, but no statistical significance was found (VR group, 2.8 vs control group, 1.8, p = 0.14). CONCLUSIONS In this study, usage of 360VR models for planning the craniotomy and rehearsing with various clip sizes and configurations resulted in an 80-minute decrease in procedure time. These findings have suggested the potential of VR technology in improving surgical efficiency for aneurysm clipping procedures regardless of complexity, while making the procedure faster and safer.

Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

2021 ◽  
pp. 1-12
Author(s):  
Jang Hun Kim ◽  
Wonki Yoon ◽  
Chi Kyung Kim ◽  
Haewon Roh ◽  
Hee Jin Bae ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Superficial Temporal Artery ◽  
Pooled Analysis ◽  
Published Data ◽  
Efficacy And Safety ◽  
Nihss Score

<b><i>Background:</i></b> Clinical outcome in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) is not satisfactory if reperfusion treatment fails or is not tried. <b><i>Aims:</i></b> We aimed to assess the efficacy and safety of urgent superficial temporal-to-middle cerebral artery (STA-MCA) bypass surgery in selected patients. <b><i>Methods:</i></b> Patients who were diagnosed with LVO-induced AIS in the anterior circulation but had a failed intra-arterial thrombectomy (IAT) or were not tried due to IAT contraindications were prospectively enrolled. Timely urgent STA-MCA bypass surgery was performed if they showed perfusion-diffusion mismatch or symptom-diffusion mismatch in the acute phase of disease. Clinical and radiological data of these patients were assessed to demonstrate the safety and efficacy of urgent bypass procedures. A pooled analysis of published data on urgent bypass surgery in acute stroke patients was conducted and analyzed. <b><i>Results:</i></b> In 18 patients who underwent timely bypass, the National Institutes of Health Stroke Scale (NIHSS) score improved from 12.11 ± 4.84 to 9.89 ± 6.52, 1 week after surgery. Three-month and long-term (9.72 ± 5.00 months) favorable outcomes (modified Rankin Scale [mRS] scores 0–2) were achieved in 50 and 75% of the patients, respectively. The pooled analysis (117 patients from 10 articles, including ours) identified favorable mRS scores in 71.79% patients at 3 months. A significant NIHSS score improvement from 11.51 ± 4.89 to 7.59 ± 5.50 was observed after surgery with significance. Major complications occurred in 3 patients (2.6%, 3/117) without mortality. <b><i>Conclusions:</i></b> Urgent STA-MCA bypass surgery can be regarded as a safe optional treatment to prevent cerebral infarct expansion and to improve clinical and radiological outcomes in highly selected patients.

scholarly journals The impact of betamethasone on fetal pulmonary, umbilical and middle cerebral artery Doppler velocimetry and its relationship with neonatal respiratory distress syndrome

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Homeira Vafaei ◽  
Fahimeh Kaveh Baghbahadorani ◽  
Nasrin Asadi ◽  
Maryam Kasraeian ◽  
Azam Faraji ◽  
...  
Keyword(s):  
Pulmonary Artery ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Distress Syndrome ◽  
Exposed Group ◽  
Doppler Velocity ◽  
Corticosteroid Administration ◽  
The Impact

Abstract Background Prenatal corticosteroid administration is known to be an effective strategy in improving fetal pulmonary maturity. This study aimed to evaluate the impact of maternal betamethasone administration on fetal pulmonary and other arteries Doppler velocity and the correlation between RDS development and Doppler indices results. Methods Fifty one singleton pregnancies between 26 and 34 gestational weeks with a diagnosis of preterm labor were included in the exposed group and received betamethasone. Fifty one uncomplicated pregnancies were included in the non-exposed group. Fetal pulmonary, umbilical and middle cerebral arteries Doppler parameters were evaluated before and 24 to 48 h after steroid administration in the exposed group and two times at same intervals in the non-exposed group. Maternal records were matched to neonatal charts if delivery happened, and demographic and outcome data were abstracted. Results When compared with the nonexposed group, fetuses treated with corticosteroids demonstrated significantly decreased umbilical artery Pulsatility index (PI) and significantly increased the middle cerebral artery PI, pulmonary artery Acceleration time (AT) and pulmonary artery AT/ET (Ejection time), while all other indices remained similar. We found significantly decreased pulmonary artery AT in the fetuses with respiratory distress syndrome (RDS) compared to those that did not. Conclusions The results of our study showed that maternal antenatal betamethasone administration caused significant changes in the fetus blood velocity waveforms and also affected the blood flow in the pulmonary artery which led to an increase in the pulmonary artery AT and AT/ET. Among those fetuses with RDS, we found a significant decrease in the pulmonary artery AT, but we did not observe any pulmonary artery AT/ET differences.

Abstract 74: Improvement in Cerebral Hemodynamic Parameters and Outcome after Superficial Temporal Artery- Middle Cerebral Artery Bypass in Patients with Severe Steno-occlusive Disease of Intracranial Carotid and Middle Cerebral Artery

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Leonard Yeo ◽  
Prakash Paliwas ◽  
Aftab Ahmad ◽  
Arvind K Sindha ◽  
Hockluen Teoh ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Occlusive Disease ◽  
Stroke Recurrence ◽  
Hemodynamic Parameters ◽  
Bypass Group ◽  
Hmpao Spect

Background and Objective: Older and the recent extracranial-intracranial (EC/IC) bypass trials for symptomatic carotid occlusion failed to demonstrate reduction in stroke recurrence. However, role of superficial temporal artery-middle cerebral artery (STA-MCA) bypass in patients with symptomatic intracranial steno-occlusive disease has been evaluated scarcely. We evaluated serial changes in various cerebral hemodynamic parameters in patients with severe steno-occlusive disease of intracranial internal carotid (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR), treated with STA-MCA bypass surgery or medical treatment. Methods: Patients with severe steno-occlusive disease of intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using breath-holding index (BHI). Patients with impaired BHI (<0.69) were further evaluated with acetazolamide-challenged hexamethylpropyleneamine-oxime single-photon emission computed tomography (HMPAO-SPECT). STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4±1 months and followed-up for cerebral ischemic events. Results: A total of 112patients (73males, mean age 56yrs; range 23-78yrs) were included. HMPAO-SPECT demonstrated impaired CVR in 77 (69%) patients. Of them, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenged HMPAO-SPECT repeated 4±1months showed significant improvement in STA-MCA bypass group. During follow-up (mean 34months; range 18-39months), only 6/46 (13%) patients in bypass group developed cerebral ischemic events as compared to 14/31 (45%) cases on medical therapy (absolute risk-reduction 32%, p=0.008). Conclusion: STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial steno-occlusive disease results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.

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