Almanac of Clinical MedicineAlmanac of Clinical Medicine2072-05052587-9294Moscow Regional Research and Clinical Institute (MONIKI)172210.18786/2072-0505-2023-51-005Research ArticleThe results of surgery for giant aneurysms of the middle cerebral arteries: a retrospective studyPilipenkoYuri V.<p>MD, PhD, Neurosurgeon, Senior Research Fellow, 3rd Vascular Department</p>3664656@mail.ruhttps://orcid.org/0000-0003-4001-3212EliavaShalva S.<p style="font-weight: 400;">MD, PhD, Professor, Corr. Member of Russ. Acad. Sci., Neurosurgeon, Head of 3rd Vascular Department</p>Eliava@nsi.ruhttps://orcid.org/0000-0001-6103-9329KonovalovAnton N.<p>MD, PhD, Neurosurgeon, Research Fellow, 3rd Vascular Department</p>ANKonovalov@nsi.ruhttps://orcid.org/0000-0002-0932-4752GrebenevFyodor V.<p>Neurosurgeon, Postgraduate Student, 3rd Vascular Department</p>grebenevf@gmail.comhttps://orcid.org/0000-0003-2622-7804BarchunovBoris V.<p>PhD (in Phys. And Math.), Research Fellow</p>neurosrgn@yahoo.comNational Medical Research Center for Neurosurgery named after Academician N.N. BurdenkoCenter for Physical Instrumentation of Prokhorov General Physics Institute1005202351132442008202205042023Copyright © 2023, Pilipenko Y.V., Eliava S.S., Konovalov A.N., Grebenev F.V., Barchunov B.V.2023<p><strong>Background</strong>: Surgical treatment of middle cerebral artery (MCA) giant aneurysms is a challenging task. The information on its current principles is rather limited, with the publications based on isolated case reports and small series.</p>
<p><strong>Aim</strong>: To identify the types of procedures and evaluate the results of surgery in patients with giant MCA aneurysms.</p>
<p><strong>Materials and methods</strong>: We retrospectively analyzed the data on 55 patients who had undergone surgery for MCA giant aneurysms in the Burdenko Neurosurgery Center from 2010 to 2021. Thereafter 52 patients were followed up for 6 to 120 months (for 53.1 33.7 months on average).</p>
<p><strong>Results</strong>: The giant MCA aneurysms were located at the M1 segment bifurcation in 33 (60%) patients, within the M1 segment, in 11 (20%), M2 in 7 (12.7%), and M3 and M4 in 4 (7.3%) patients. There were 32 (58.2%) saccular and 23 (41.8%) fusiform aneurysms. Surgical interventions for MCA giant aneurysms included their neck clipping (50.9%, n = 28), clipping with formation of the arterial lumen (3.6%, n = 2), bypass procedures (34.5%, n = 19), wrapping (3.6%, n = 2), and endovascular procedures (7.3%, n = 4). Perioperative worsening of the neurologic status (The Modified Rankin Scale, mRS) was observed in 50.9% (n = 28) of the patients, and the death rate was 1.8% (n = 1). The complete closure of giant aneurysms was achieved in 78.2% (n = 43) of the cases. The long-term outcome was favorable in 76.9% of the patients (40 from 52 available for the follow up).</p>
<p><strong>Conclusion</strong>: Microsurgical clipping and bypass types of surgery were the most common surgical procedures for the treatment of MCA giant aneurysms. These procedures are technically complex and are associated with a relatively high number of complications. The main directions of future studies could be in the search for new and more precise diagnostic assessment of the collateral circulation in the cortical MCA branches, improvement of the algorithm for the bypass selection, as well as an investigation of the long-term results of endovascular and combined treatments. A thorough long-term postoperative patient follow-up and the possibility of high quality control angiography are of major importance.</p>bypassclippingcomplex aneurysmsgiant aneurysmmiddle cerebral artery aneurysmssurgical treatmentэкстра-интракраниальный микроанастомозклипированиесложная аневризмагигантская аневризмааневризма средней мозговой артериихирургическое лечение[Park W, Chung J, Ahn JS, Park JC, Kwun BD. Treatment of Large and Giant Middle Cerebral Artery Aneurysms: Risk Factors for Unfavorable Outcomes. World Neurosurg. 2017;102:301–312. doi: 10.1016/j.wneu.2017.03.028.][Rinne J, Hernesniemi J, Niskanen M, Vapalahti M. Analysis of 561 patients with 690 middle cerebral artery aneurysms: anatomic and clinical features as correlated to management outcome. Neurosurgery. 1996;38(1):2–11. doi: 10.1097/00006123-199601000-00002.][Rodríguez-Hernández A, Sughrue ME, Akhavan S, Habdank-Kolaczkowski J, Lawton MT. Current management of middle cerebral artery aneurysms: surgical results with a "clip first" policy. Neurosurgery. 2013;72(3):415–427. doi: 10.1227/NEU.0b013e3182804aa2.][Kivipelto L, Niemelä M, Meling T, Lehecka M, Lehto H, Hernesniemi J. Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree. J Neurosurg. 2014;120(2):398–408. doi: 10.3171/2013.10.JNS13738.][Nurminen V, Lehecka M, Chakrabarty A, Kivisaari R, Lehto H, Niemelä M, Hernesniemi J. Anatomy and morphology of giant aneurysms – angiographic study of 125 consecutive cases. Acta Neurochir (Wien). 2014;156(1):1–10. doi: 10.1007/s00701-013-1933-4.][Hacein-Bey L, Connolly ES Jr, Mayer SA, Young WL, Pile-Spellman J, Solomon RA. Complex intracranial aneurysms: combined operative and endovascular approaches. Neurosurgery. 1998;43(6):1304–1312; discussion 1312–1313. doi: 10.1097/00006123-199812000-00020.][Andaluz N, Zuccarello M. Treatment strategies for complex intracranial aneurysms: review of a 12-year experience at the University of Cincinnati. Skull Base. 2011;21(4):233–242. doi: 10.1055/s-0031-1280685.][Hanel RA, Spetzler RF. Surgical treatment of complex intracranial aneurysms. Neurosurgery. 2008;62(6 Suppl 3):1289–1297; discussion 1297–1299. doi: 10.1227/01.neu.0000333794.13844.d9.][Eliava S, Pilipenko Y, Shekhtman O, Konovalov A. Reversal of intraoperative arterial thrombosis with a fibrinolytic agent when treating large and giant partially thrombosed aneurysms of the middle cerebral artery. J Neurosurg. 2016;124(4):1114–1122. doi: 10.3171/2015.2.JNS142655.][Sadik AR, Budzilovich GN, Shulman K. Giant aneurysm of middle cerebral artery: a case report. J Neurosurg. 1965;22:177–181. doi: 10.3171/jns.1965.22.2.0177.][Drake CG. Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg. 1979;26:12–95. doi: 10.1093/neurosurgery/26.cn_suppl_1.12.][Zhu W, Liu P, Tian Y, Gu Y, Xu B, Chen L, Zhou L, Mao Y. Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies. Acta Neurochir (Wien). 2013;155(8):1481–1491. doi: 10.1007/s00701-013-1751-8.][Natarajan SK, Zeeshan Q, Ghodke BV, Sekhar LN. Brain Bypass Surgery for Complex Middle Cerebral Artery Aneurysms: Evolving Techniques, Results, and Lessons Learned. World Neurosurg. 2019;130:e272–e293. doi: 10.1016/j.wneu.2019.06.059.][Dean BL, Wallace RC, Zabramski JM, Pitt AM, Bird CR, Spetzler RF. Incidence of superficial sylvian vein compromise and postoperative effects on CT imaging after surgical clipping of middle cerebral artery aneurysms. AJNR Am J Neuroradiol. 2005;26(8):2019–2026.][Kageyama Y, Fukuda K, Kobayashi S, Odaki M, Nakamura H, Satoh A, Watanabe Y. Cerebral vein disorders and postoperative brain damage associated with the pterional approach in aneurysm surgery. Neurol Med Chir (Tokyo). 1992;32(10):733–738. doi: 10.2176/nmc.32.733.][Muhammad S, Tanikawa R, Lawton M, Regli L, Niemelä M, Korja M. Microsurgical dissection of Sylvian fissure-short technical videos of third generation cerebrovascular neurosurgeons. Acta Neurochir (Wien). 2019;161(9):1743–1746. doi: 10.1007/s00701-019-03999-x.][Maekawa H, Hadeishi H. Venous-Preserving Sylvian Dissection. World Neurosurg. 2015;84(6):2043–2052. doi: 10.1016/j.wneu.2015.07.050.][Pancucci G, Potts MB, Rodríguez-Hernández A, Andrade H, Guo L, Lawton MT. Rescue Bypass for Revascularization After Ischemic Complications in the Treatment of Giant or Complex Intracranial Aneurysms. World Neurosurg. 2015;83(6):912–920. doi: 10.1016/j.wneu.2015.02.001.][Tayebi Meybodi A, Huang W, Benet A, Kola O, Lawton MT. Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization. J Neurosurg. 2017;127(3):463–479. doi: 10.3171/2016.7.JNS16772.][Matsukawa H, Kamiyama H, Miyazaki T, Kinoshita Y, Ota N, Noda K, Shonai T, Takahashi O, Tokuda S, Tanikawa R. Surgical Treatment of Middle Cerebral Artery Aneurysms: Aneurysm Location and Size Ratio as Risk Factors for Neurologic Worsening and Ischemic Complications. World Neurosurg. 2018;117:e563–e570. doi: 10.1016/j.wneu.2018.06.077.][Fujii K, Fukui M, Matsubara T, Nagata S, Fujiwara S, Matsushima T, Hasuo K. Microsurgical procedures for management of giant middle cerebral aneurysm causing increased intracranial pressure. Surg Neurol. 1989;32(5):366–371. doi: 10.1016/0090-3019(89)90141-9.][Amin-Hanjani S, Alaraj A, Charbel FT. Flow replacement bypass for aneurysms: decision-making using intraoperative blood flow measurements. Acta Neurochir (Wien). 2010;152(6):1021–1032; discussion 1032. doi: 10.1007/s00701-010-0635-4.][Hu P, Zhang HQ, Li XY, Tong XZ. Double-Barrel Superficial Temporal Artery to Proximal Middle Cerebral Artery Bypass to Treat Complex Intracranial Aneurysms: A Reliable High Blood Flow Bypass. World Neurosurg. 2019;125:e884–e890. doi: 10.1016/j.wneu.2019.01.203.][Rustemi O, Amin-Hanjani S, Shakur SF, Du X, Charbel FT. Donor Selection in Flow Replacement Bypass Surgery for Cerebral Aneurysms: Quantitative Analysis of Long-term Native Donor Flow Sufficiency. Neurosurgery. 2016;78(3):332–341; discussion 341–342. doi: 10.1227/NEU.0000000000001074.][Nussbaum ES, Kallmes KM, Lassig JP, Goddard JK, Madison MT, Nussbaum LA. Cerebral revascularization for the management of complex intracranial aneurysms: a single-center experience. J Neurosurg. 2018:1–11. doi: 10.3171/2018.4.JNS172752. Epub ahead of print.][Nakajima H, Kamiyama H, Nakamura T, Takizawa K, Tokugawa J, Ohata K. Direct surgical treatment of giant middle cerebral artery aneurysms using microvascular reconstruction techniques. Neurol Med Chir (Tokyo). 2012;52(2):56–61. doi: 10.2176/nmc.52.56.][Seo BR, Kim TS, Joo SP, Lee JM, Jang JW, Lee JK, Kim JH, Kim SH. Surgical strategies using cerebral revascularization in complex middle cerebral artery aneurysms. Clin Neurol Neurosurg. 2009;111(8):670–675. doi: 10.1016/j.clineuro.2009.06.002.][Wessels L, Fekonja LS, Vajkoczy P. Bypass surgery of complex middle cerebral artery aneurysms – technical aspects and outcomes. Acta Neurochir (Wien). 2019;161(10):1981–1991. doi: 10.1007/s00701-019-04042-9.][Wang L, Lu S, Cai L, Qian H, Tanikawa R, Shi X. Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms. Neurosurg Focus. 2019;46(2):E10. doi: 10.3171/2018.11.FOCUS18457.][Xu F, Xu B, Huang L, Xiong J, Gu Y, Lawton MT. Surgical Treatment of Large or Giant Fusiform Middle Cerebral Artery Aneurysms: A Case Series. World Neurosurg. 2018;115:e252–e262. doi: 10.1016/j.wneu.2018.04.031.][van Doormaal TP, van der Zwan A, Verweij BH, Han KS, Langer DJ, Tulleken CA. Treatment of giant middle cerebral artery aneurysms with a flow replacement bypass using the excimer laser-assisted nonocclusive anastomosis technique. Neurosurgery. 2008;63(1):12–20; discussion 20–22. doi: 10.1227/01.NEU.0000335066.45566.D1.][Drake CG, Peerless SJ, Ferguson GG. Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation. J Neurosurg. 1994;81(5):656–665. doi: 10.3171/jns.1994.81.5.0656.][Diaz FG, Guthikonda M, Guyot L, Velardo B, Gordon V. Surgical management of complex middle cerebral artery aneurysms. Neurol Med Chir (Tokyo). 1998;38 Suppl:50–57. doi: 10.2176/nmc.38.suppl_50.][Zanaty M, Chalouhi N, Tjoumakaris SI, Gonzalez LF, Rosenwasser R, Jabbour P. Flow diversion for complex middle cerebral artery aneurysms. Neuroradiology. 2014;56(5):381–387. doi: 10.1007/s00234-014-1339-x.][Cagnazzo F, Mantilla D, Lefevre PH, Dargazanli C, Gascou G, Costalat V. Treatment of Middle Cerebral Artery Aneurysms with Flow-Diverter Stents: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2017;38(12):2289–2294. doi: 10.3174/ajnr.A5388.][Shi ZS, Ziegler J, Duckwiler GR, Jahan R, Frazee J, Ausman JI, Martin NA, Viñuela F. Management of giant middle cerebral artery aneurysms with incorporated branches: partial endovascular coiling or combined extracranial-intracranial bypass – a team approach. Neurosurgery. 2009;65(6 Suppl):121–129; discussion 129–131. doi: 10.1227/01.NEU.0000335173.80605.1D.][David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg. 1999;91(3):396–401. doi: 10.3171/jns.1999.91.3.0396.][Brown MA, Parish J, Guandique CF, Payner TD, Horner T, Leipzig T, Rupani KV, Kim R, Bohnstedt BN, Cohen-Gadol AA. A long-term study of durability and risk factors for aneurysm recurrence after microsurgical clip ligation. J Neurosurg. 2017;126(3):819–824. doi: 10.3171/2016.2.JNS152059.]