Heros R C, Ojemann R G, Crowell R M
Neurosurgery. 1982 Mar;10(3):308-13. doi: 10.1227/00006123-198203000-00002.
Aneurysms of the bifurcation of the middle cerebral artery (MCA) can be approached through a small incision in the anterior portion of the superior temporal gyrus. The pterion and the lateral aspect of the lesser wing of the sphenoid bone are removed. The aneurysm is approached, using microsurgical techniques, by following the main divisions of the MCA to the parent trunk and the base of the aneurysm. Once the parent vessel and the origin of the major divisions are clearly identified, it is usually preferable to dissect and mobilize the entire aneurysmal complex to elucidate the anatomy and prepare the neck for clipping. This approach offers the advantages of minimal brain retraction and minimal manipulation of the main trunk and perforators of the MCA. In addition, it allows a more complete exposure of the aneurysmal complex and facilitates dissection behind the aneurysm, which is more difficult when the aneurysm is approached from the front by opening the sylvian fissure medially to laterally. A potential disadvantage of this method is that proximal control is not obtained until the base of the aneurysm is reached, but this has not been a problem in our experience. Other disadvantages are the need for a slightly larger bone flap and the potentially increased risk of epilepsy. This approach is not suitable when the main trunk of the MCA is short and the aneurysm is in front of the insula. It is also not recommended for the rare cases in which the aneurysm points back over the insula. During a 6-year period, this approach was used in 49 of 58 cases of MCA aneurysm. The only deaths in this group occurred in patients who were in deep coma before operation. Two patients were made worse by operative complications, and 2 more worsened as a result of postoperative vasospasm. There was a significant incidence of thrombophlebitis and pulmonary embolism in this series.
大脑中动脉（MCA）分叉处的动脉瘤可通过颞上回前部的小切口进行处理。去除翼点和蝶骨小翼的外侧部分。使用显微外科技术，沿着MCA的主要分支追踪至母干和动脉瘤基部来处理动脉瘤。一旦清楚地识别出母血管和主要分支的起源，通常最好解剖并游离整个动脉瘤复合体，以阐明其解剖结构并准备夹闭瘤颈。这种方法具有脑牵拉最小以及对MCA主干和穿支操作最少的优点。此外，它能更完整地暴露动脉瘤复合体，并便于在动脉瘤后方进行解剖，而从前方通过内侧向外侧打开外侧裂处理动脉瘤时，此处解剖更为困难。该方法的一个潜在缺点是直到到达动脉瘤基部才能实现近端控制，但根据我们的经验这并非问题。其他缺点是需要稍大的骨瓣以及癫痫风险可能增加。当MCA主干较短且动脉瘤位于岛叶前方时，这种方法不适用。对于动脉瘤指向岛叶后方的罕见情况也不推荐使用。在6年期间，58例MCA动脉瘤中有49例采用了这种方法。该组中仅有的死亡病例发生在术前处于深昏迷状态的患者。2例患者因手术并发症病情加重，另外2例因术后血管痉挛病情恶化。该系列中血栓性静脉炎和肺栓塞的发生率较高。
