Surgical Treatment of Middle Cerebral Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

Abstract

Background and Objective Clipping is still considered the treatment of choice for middle cerebral artery (MCA) aneurysms due to their angioarchitectural characteristics as they are often bifurcation dysplasias, needing a complex reconstruction rather than a simple exclusion. Thus, maintaining this surgical expertise is of paramount importance to train of young cerebrovascular surgeons. To balance for the increasingly limited experience due the worldwide general inclination toward the endovascular approaches, it is important to provide to the young neurosurgeons rules and operative nuances to guide this complex surgery. We describe the technical algorithm we use to teach our residents to approach ruptured and unruptured MCA aneurysms, which may help to develop a procedural memory useful to perform an effective and safe surgery. Materials and Methods We reviewed our last 10 years' institutional experience of about 400 cases of ruptured and unruptured MCA aneurysms clipping, analyzing our technical refinements and the difficulties in residents and young neurosurgeons teaching, to establish fundamental key-points and design a didactic algorithm that includes operative instructions and safety rules. Results We recognized seven pragmatic technical key points regarding craniotomy, sylvian fissure opening, basal cisternostomy, proximal vessel control, lenticulostriate arteries preservation, aneurysm neck microdissection, and clipping to use as a didactic algorithm for teaching residents, and as operative instructions for inexperienced neurosurgeons. Conclusion In the setting of clipping MCA aneurysms, respect for surgical rules is of paramount importance to perform an effective and safe procedure, ensure the best aneurysm exclusion, and preserve the flow in collaterals and perforators.

Comparison Between Intrasylvian and Intracerebral Hematoma Associated with Ruptured Middle Cerebral Artery Aneurysms: Clinical Implications, Technical Considerations, and Outcome Evaluation

“…Although an early open surgery still represents the treatment of choice in many neurosurgical units in almost all cases of MCA aneurysms especially when associated with larger ICH or ISH [17], different treatment paradigms are prevalent in other centers where the vascular neurosurgery expertise has progressively declining and the endovascular obliteration emerges as the rst approach in all ruptured aneurysms [14][15][16], including those associated with hematomas whose evacuation is therefore delayed after having secured the aneurysm. Nevertheless, a combined endovascular obliteration rst and hematoma evacuation after has been advocated also by teams having strong expertise in vascular neurosurgery as reasonable option in selected patients with SAH and associated ICH as this treatment paradigm can transform a complex surgery in an easier and quicker decompression [19].…”

Clipping versus coiling for treatment of middle cerebral artery aneurysms: a retrospective Italian multicenter experience

“…Accordingly, their treatment should be considered as a bifurcation reconstruction rather than a simple aneurysm clipping. During this complex reconstruction, exclusion of the sac, preservation from deformation of the parent vessels ostia, and avoidance of perforators occlusion have to be guaranteed at the same time adopting a fine dissection and respecting specific clipping rules [ 4 , 9 – 11 ].…”

“…In fact, despite MCA aneurysms are usually considered saccular in morphology, actually, they appear more similar to a bifurcation dysplasia, often with a large neck involving the origin of the collaterals, and their exclusion should be considered a bifurcation reconstruction rather than a simple aneurysm clipping. Their clipping have to guarantee at the same time exclusion of the sac, preservation of parent vessels ostia deformation, and perforators occlusion [ 4 ].…”

Geometry and Symmetry of Willis’ Circle and Middle Cerebral Artery Aneurysms Development

“…Also, aneurysms develop more often in bifurcations with relatively sharp angles, where the bloodstream deviates significantly from the direction of flow of the parent artery, than in bifurcations with more obtuse angles, where the bloodstream deviates relatively little from the direction of flow of the parent artery [3,21,26]. This last geometrical characteristic would seem to be the most important predisposing feature compared with the circle of Willis' symmetry for the risk of MCA aneurysm development, aneurysms that are often more similar to a bifurcation dysplasia than true saccular aneurysms [38][39][40].…”