Bhide Anuj Arun, Yamada Yashuhiro, Kato Yoko, Kawase Tsukasa, Tanaka Riki, Miyatani Kyosuke, Kojima Daijiro, Sayah Ahmed
Department of Neurosurgery, Fujita Health University Babuntane Hospital, Nagoya, Japan.
Department of Neurosurgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India.
Asian J Neurosurg. 2020 Oct 19;15(4):959-965. doi: 10.4103/ajns.AJNS_5_20. eCollection 2020 Oct-Dec.
Complex middle cerebral artery (MCA) aneurysms are defined as large (≥10 mm) or giant (≥25 mm) aneurysms with M2 branches arising from the aneurysm rather than M1 segments and usually require some form of reconstruction of the bifurcation. Their management is difficult and surgery is preferred over endovascular modalities because of their peculiar angioarchitecture and association with critical branch points or perforators.
The study was aimed at analyzing surgically managed complex MCA aneurysms and discussing characteristics not favorable for endovascular management, surgical nuances and clipping strategies, patient outcomes, and newer diagnostic modalities which help improve management.
Nine cases of surgically operated complex MCA aneurysms were identified from January 2017 to July 2019. The aneurysm characteristics, surgical nuances, clipping strategies, patient outcomes and points not favoring endovascular management were tabulated and analyzed.
The mean maximum aneurysm diameter was 13.4 mm and the mean fundus/neck ratio was 1.6. The average microscope time was 124 min, and the most common method was clip reconstruction. The average number of clips used was 2.7 and the mean follow-up was 13 months. All patients have good postoperative outcome (Modified Rankin Score 0-2). The complete occlusion rate was 88.9% with one intraoperative voluntary residual sac which was coated. Computational fluid dynamic study results done preoperatively correlated with intraoperative findings.
MCA aneurysms pose a significant challenge for endovascular treatment because of various factors such as luminal thrombi, complex angio-architecture, precarious branch/perforator locations, broad necks, and fusiform characteristics. Surgical management in experienced hands can tackle all these problems with an armamentarium of clipping techniques and bypass procedures.
复杂大脑中动脉（MCA）动脉瘤被定义为大型（≥10毫米）或巨大型（≥25毫米）动脉瘤，其M2分支起源于动脉瘤而非M1段，通常需要某种形式的分叉重建。由于其特殊的血管结构以及与关键分支点或穿支的关联，其治疗具有挑战性，手术治疗优于血管内治疗方式。
本研究旨在分析手术治疗的复杂MCA动脉瘤，讨论不利于血管内治疗的特征、手术细节和夹闭策略、患者预后以及有助于改善治疗的新型诊断方式。
从2017年1月至2019年7月确定9例接受手术治疗的复杂MCA动脉瘤病例。将动脉瘤特征、手术细节、夹闭策略、患者预后以及不利于血管内治疗的因素制成表格并进行分析。
动脉瘤平均最大直径为13.4毫米，平均瘤底/瘤颈比为1.6。平均显微镜下手术时间为124分钟，最常用的方法是夹闭重建。平均使用夹子数量为2.7个，平均随访时间为13个月。所有患者术后预后良好（改良Rankin评分0 - 2分）。完全闭塞率为88.9%，1例术中自愿残留囊腔进行了涂层处理。术前进行的计算流体动力学研究结果与术中发现相关。
由于管腔内血栓、复杂的血管结构、不稳定的分支/穿支位置、宽颈和梭形特征等多种因素，MCA动脉瘤给血管内治疗带来了重大挑战。经验丰富的术者采用手术治疗，通过一系列夹闭技术和搭桥手术可以解决所有这些问题。
