Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
World Neurosurg. 2022 May;161:152. doi: 10.1016/j.wneu.2022.02.100. Epub 2022 Mar 4.
Some giant intracranial aneurysms can develop serpentine morphology, secondary to a peculiar near-complete intra-aneurysmal thrombosis. The resulting complex angioarchitecture, along with atypical clinical presentations (i.e., mass effect, distal ischemia) seen, makes management of such aneurysms technically challenging. These aneurysms are not amenable to endovascular treatment, and hence the only remaining treatment option is a tailored microsurgical procedure (clipping/parent vessel occlusion or reconstruction/trapping/aneurysmorrhaphy) accompanied by a safety bypass (high-flow, low-flow, or in situ bypass, subject to dependence of distal circulation on proximal trunk with reference to aneurysm). The microsurgical procedure can be performed either in 1 or 2 stages (bypass followed by aneurysm treatment at a later date). Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass followed by aneurysm trapping/decompression is the most routinely performed microsurgical procedure for such aneurysms. The operative video illustrates an alternative surgical treatment of a giant serpentine aneurysm of the MCA: resection and end-to-end anastomosis. A 20-year-old man underwent microsurgery for a giant right MCA serpentine aneurysm. In view of the poor distal flow in the ipsilateral MCA territory, an STA-MCA bypass with aneurysm trapping/decompression was planned. Intraoperatively, the presence of a stretched and elongated ipsilateral MCA (secondary to aneurysm mass effect) plus the relatively narrow neck of the thrombosed aneurysm provided a rare opportunity to perform resection and end-to-end anastomosis (Video 1). Intraoperative and postoperative angiography confirmed the anastomosis patency. The patient's recovery was uneventful. This treatment can save operating time, eliminate donor artery-related morbidity, and offer a surgical alternative to the conventional strategy of STA-MCA bypass.
一些巨大的颅内动脉瘤由于独特的近完全瘤内血栓形成，可能会发展出蛇形形态。由此产生的复杂血管结构，以及不典型的临床表现（即占位效应、远端缺血），使得这些动脉瘤的治疗在技术上具有挑战性。这些动脉瘤不适于血管内治疗，因此唯一剩下的治疗选择是进行量身定制的显微手术（夹闭/母血管闭塞或重建/套扎/动脉瘤缝合术），并辅以安全旁路（高流量、低流量或原位旁路，取决于远端循环对动脉瘤近端主干的依赖性）。显微手术可以在 1 个或 2 个阶段进行（旁路后在以后的日期进行动脉瘤治疗）。颈外动脉（STA）-大脑中动脉（MCA）旁路后进行动脉瘤夹闭/减压是治疗此类动脉瘤最常规的显微手术。手术视频展示了 MCA 巨大蛇形动脉瘤的另一种手术治疗方法：切除和端端吻合。一名 20 岁男性因右侧 MCA 巨大蛇形动脉瘤接受了显微手术。鉴于同侧 MCA 区域的远端血流较差，计划进行 STA-MCA 旁路加动脉瘤夹闭/减压。术中发现同侧 MCA 拉伸和延长（由于动脉瘤占位效应），加上血栓形成的动脉瘤相对较窄的颈部，为进行切除和端端吻合提供了一个罕见的机会（视频 1）。术中及术后血管造影证实吻合通畅。患者恢复顺利。这种治疗方法可以节省手术时间，消除供体动脉相关的发病率，并为 STA-MCA 旁路的常规策略提供一种手术替代方案。
