Unexpected Rupture of a Giant Lobulated Thrombotic Middle Cerebral Artery Aneurysm and Emergency Surgical Treatment With Thrombectomy: A Case Report and Review of the Literature

Abstract

IntroductionThe treatment of giant intracranial aneurysms is one of the most challenging cerebrovascular problems of neurosurgery. We report the rupture of a giant, lobulated, and almost completely thrombosed middle cerebral artery (MCA) aneurysm that is the ninth such report in the literature. We also investigated additional solutions used in the treatment of this patient.Case PresentationA 58-year-old man had been admitted with headache 8 years previously (in 2005), and a giant MCA aneurysm was detected. Two separate endovascular interventions were performed, and both failed. The patient began to live with the giant aneurysm. As there was a large thrombosis filling the aneurysm lumen during the previous endovascular procedures, the aneurysm was not expected to rupture. However, a rupture eventually occurred, in 2013. Even if an aneurysm is very large, lobulated, old, and almost completely thrombosed, it can suddenly bleed. During surgery on this patient, we observed severe cerebral vasospasm caused by a giant thrombosed aneurysmal rupture. Despite the complications, surgery is a life-saving treatment for this emergency when other strategies are not possible. Thrombectomy and clipping are approaches that require a great deal of courage for the neurosurgeon, in terms of entering the risky area within the aneurysm.ConclusionsWe believe that it would be more appropriate to plan for combined treatment with surgical and endovascular approaches before the emergency condition could occur.

Aneurismas gigantes da artéria cerebral média. Revisão de literatura

“…Os fatores que influenciam a trombose são a liberação de fatores de coagulação pelo trombo e placas ateroscleróticas, o estreitamento anatômico, vasoespasmo e a alteração do endotélio nas áreas onde os clipes temporários são aplicados. Foi observada em 18,9% dos 53 pacientes, e dentre eles, 21 eram aneurismas gigantes de ACM 39 .…”

“…Ademais, quando a fibrinólise falhar para restauração do fluxo, a revascularização da porção distal das artérias com trombo é realizada. O intuito dessa abordagem é encurtar o tempo necessário para a oclusão, remover o trombo, lavar a luz do aneurisma antes do corte e precaver a falta de fluxo sanguíneo em um ou mais ramos da ACM após a oclusão com trombectomia e a trombose intraoperatória 39 .…”

“…É uma técnica bem estabelecida, porém no tratamento de aneurismas gigantes com preservação do vaso original tem altas taxas de recorrência variando entre 37,5% a 90% e taxas de reabordagens com uma porcentagem de até 14%. Apesar de a modalidade de embolização assistido com stent melhore a durabilidade do tratamento, a taxa de recorrência se mantém alta com 20 a 57% 39 .…”