Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
World Neurosurg. 2019 Jun;126:e1387-e1398. doi: 10.1016/j.wneu.2019.03.109. Epub 2019 Mar 19.
Optimal management of complex anterior circulation aneurysms is an enigmatic challenge because of frequent involvement of major vessel bifurcation, choroidal vessels, and lenticulostriate/thalamostriate perforators. Cerebral ischemia associated with prolonged clipping time is a major concern pertinent to their surgical management, especially in patients with poor cross-flow. To circumvent this hurdle, single/double-barrel low-flow superficial temporal artery (STA) to middle cerebral artery (M3/M4-MCA) can be performed, which can maintain distal cerebral perfusion while facilitating safe clip reconstruction of complex MCA and supraclinoidal internal carotid artery (ICA) aneurysms involving ICA bifurcation or supraclinoidal ICA aneurysms with poor cross-circulation-insurance bypass, as well as supplement/alter blood flow after MCA aneurysm trapping-flow-alteration bypass.
A retrospective chart review of consecutive neurosurgical patients operated over 2 years at this center was performed. Patients with complex MCA and ICA aneurysms who were treated with STA-MCA bypass were included. The clinical profile, pre- and postoperative images, intraoperative imaging, and patient outcomes were recorded. Surgical reconstruction of aneurysm was the treatment of choice due to involvement of choroidal/thalamostriate perforators, MCA/ICA bifurcation, complex aneurysm morphology, or dissecting/thrombosed nature of aneurysm. STA-MCA low-flow bypass was performed using M3/M4 segment of MCA as the recipient in anticipation of prolonged temporary clipping time on M1-MCA, supraclinoidal ICA aneurysms with suspected ICA terminus involvement, or need for possible trapping of fusiform MCA aneurysm. The saccular/fusiform part of aneurysm was clip reconstructed and the partially thrombosed dissecting segment was opened for thrombectomy and trapped using proximal and distal clips after good patency of bypass was confirmed. The distal MCA flow was restored adequately and confirmed intraoperatively using indocyanine green angiography and micro-Doppler ultrasonography.
MCA (n = 4) and supraclinoid-ICA (n = 1) aneurysms were managed successfully using this strategy, which involved 6 STA-MCA bypass procedures (insurance and flow-alteration bypass, 3 each). Postoperative check angiograms demonstrated patent bypass in all 5 patients. Four patients had favorable outcome (modified Rankin Scale score 0/1); one had recovering hemiparesis and aphasia (modified Rankin Scale score 4).
This series highlights the surgical strategy and safety for successfully managing complex MCA and ICA aneurysms using low-flow STA-MCA revascularization procedures.
由于涉及主要血管分叉、脉络膜血管和纹状体/丘脑纹状体穿通支，复杂前循环动脉瘤的最佳管理是一个神秘的挑战。与延长夹闭时间相关的脑缺血是与手术管理相关的主要关注点，尤其是在血流交叉差的患者中。为了克服这一障碍，可以进行单/双筒低流量颞浅动脉（STA）至大脑中动脉（M3/M4-MCA）吻合术，在安全重建复杂 MCA 和颈内动脉（ICA）分叉处涉及 MCA 和岩骨内段ICA 动脉瘤或血流交叉差的岩骨内段ICA 动脉瘤的同时，保持远端脑灌注，并补充/改变 MCA 动脉瘤夹闭-血流改变旁路后的血流。
对该中心 2 年内连续接受神经外科治疗的患者进行回顾性图表分析。纳入接受 STA-MCA 旁路治疗的复杂 MCA 和 ICA 动脉瘤患者。记录患者的临床特征、术前和术后影像、术中影像和患者结局。由于脉络膜/丘脑纹状体穿通支、MCA/ICA 分叉、复杂动脉瘤形态或动脉瘤的夹层/血栓形成性质，手术重建动脉瘤是治疗的首选方法。STA-MCA 低流量旁路使用 MCA 的 M3/M4 段作为受体，预计在 M1-MCA 上进行长时间临时夹闭，在怀疑涉及 ICA 末端的岩骨内段 ICA 动脉瘤或可能需要夹闭梭形 MCA 动脉瘤时进行。动脉瘤的囊状/梭形部分用夹闭重建，部分血栓形成的夹层段打开取栓，并在旁路良好通畅后用近端和远端夹闭夹闭。术中使用吲哚菁绿血管造影和微多普勒超声确认 MCA 远端血流充足。
4 例 MCA（n=4）和 1 例岩骨内段 ICA（n=1）动脉瘤成功采用该策略治疗，共进行 6 例 STA-MCA 旁路手术（保险和血流改变旁路各 3 例）。术后复查血管造影显示所有 5 例患者旁路通畅。4 例患者预后良好（改良 Rankin 量表评分 0/1）；1 例患者遗留偏瘫和失语症（改良 Rankin 量表评分 4）。
本系列强调了使用低流量 STA-MCA 再血管化手术成功治疗复杂 MCA 和 ICA 动脉瘤的手术策略和安全性。
