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KMID : 0376119980250010143
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Medical Journal of the Red Cross Hospital
1998 Volume.25 No. 1 p.143 ~ p.147
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Surgical Treatment of MCA Bifurcation or Trifurcation Aneurysms
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Hong Seung-Koan
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Abstract
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Nowadays the standard treatment to prevent the rupture or rebleeding of cerebral aneurysms is the microneurosurgical neck clipping. Not infrequent are the situations when a safe and complete aneurysmal neck clipping is difficult. Being located relatively superficial, aneurysms at the knee portion of the middle cerebral artery (MCA) can be managed by various surgical tactics to achieve a complete isolation of the aneurysm from the systemic circulation or to prevent their rupture. The author retrospectively analyzed 39 cases with 41 aneurysms at the bi- or trifurcation of the MCA which he
operated upon by direct surgical approaches for recent 6 and a half years, with an emphasis on the anatomical findings of the aneurysms and surgical methods to treat the aneurysms. Twelve of the 39 patients (30.8%) had incidental unruptured aneurysms, and 27 patients had ruptured aneurysms at the flee portion of the MCA. Among the total 41 aneurysms, thirty-two (y8.0%) were small, three (7.3%) were large, and six (14.6%) were abortive aneurysms in size; none were giant aneurysms. Among the 27 cases with ruptured aneurysms, 9 patients (33.3%) had intracerebral hematomas (ICH) and their clinical status on admission and treatment results were much poorer than those without ICH. Preoperative rebleeding occurred in 2 patients (7.4%). MCA hee portions were bifurcated in 35 patients (89.7%), and trifurcated in 4 cases (10.3%). Thirty of 41 aneurysms (73.2%) were treated by the neck clipping, three (7.3%) by the neck clipping plus wrapping of the residual neck, and eight (19.5%) by the wrapping. Six of the 8 aneurysms managed by the wrapping were abortive ones without any clippable necks. Most of the times when the local hypotension was needed, the temporary distal Ml clipping was adapted. However, in the 2 cases with complicated configurations the temporary trapping of the aneurysm was performed in order to achieve the complete neck clipping. Intraoperative premature rupture of the aneurysm occurred in 2 cases; in both of them, the premature rupture happened in the dissection stage and the complete neck clipping was successfully acomplished. In surgical approaches to the anteroinferiorly-directed MCA flee portion aneurysms, lateral transsylvian or superior temporal gyrus approaches are better. The dome of those aneurysms is usually located proximal to their necks within the sylvian fissure and frequently adhered to the adjacent frontal or temporal cortex on the very way of the medial transsylvian approach. In the aneurysms directed otherwise, no difference would be made by choosing any one of the three approaches mentioned above. Anteroinferiorly directed MCA bifurcation aneurysms are commonly broad-necked and/or multilobulated, and commonly demand both multiple clips for a complete neck ligation and a wrapping of the residual neck. When the dissection and clipping of the aneurysmal neck are complicated and difficult, a temporary trapping followed by an aspiration and deflation of the aneurysm sac can be helpful. The complete trapping,
resection and anastomosis, aneurysmorrhaphy, or extracranial-intracranial arterial bypass and trapping should be considered for the management of unclippable MCA aneurysms.
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KEYWORD
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Middle cerebral artery bifurcation, Aneurysms, Surgical treatment,
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