Journal of the Louisiana State Medical Society
Case 2 53-year-old man presented with complaints of severe headache of sudden onset. On examination, he had no neu- rologic deficits except for mild dysphasia. CT scan revealed a hyperdense lesion in the left anterior temporal lobe adjacent to the sylvian fissure. There was no subarachnoid hemor- rhage. DSA diagnosed a right MCA bifurcation aneurysm. The aneurysm measured 7.5x8.5 mm and neck measured 6 mm in width. Both the superior and inferior divisions of MCA were arising from the base of the aneurysm. He un- derwent left pterional craniotomy. At surgery, theMCAwas seen to end in the aneurysm, which had a wide neck. Both the branches of MCAwere seen to arise from the neck of the aneurysm. The aneurysm was dissected from its arachnoid adhesions, and MCA bifurcation was reconstructed using a 9 mm curved clip placed across the neck of the aneurysm sparing the origin of branches. The clip was placed parallel to the origin of branches rather than perpendicular to their origin to prevent kinking of the branches. Postoperatively, the patient improvedwell without any deficits. His dyspha- sia improved completely. Postoperative angiogram showed complete obliteration of the aneurysm (Figure 3 and 4). DISCUSSION The International SubarachnoidAneurysmTrial (ISAT) concluded that in patients with ruptured intracranial an- eurysms, endovascular coiling is more likely to result in functionally independent status at one year when compared with surgical clipping. However, the risk of rebleeding is definitely higher after coiling than clipping. 1 In a subsequent subgroup analysis of patients aged 65 and above, the authors concluded that in good grade patients with anterior circula- tion aneurysms, endovascular therapy should be favored over clipping, except in patients with MCA aneurysms (where clipping resulted in significantly better outcome at one year than coiling). 7 Traditionally, surgical clipping has been the standard of care for MCA aneurysms. Endovascular therapy, although initially considered to be a suboptimal option due to the unfavorable morphology of these aneurysms, has evolved rapidly over the last few years. A recent study reported good outcome (GOS 5) in 70.5% and favorable outcome (GOS 4 and 5) in 80%of the patients. 8 Regli et al. first reported the results of endovascular treatment of MCA aneurysms in 1999. 9 In their series of 34 unruptured MCA aneurysms, only 6% (n=2) were success- fully coiled with the GDC system. In 32%, the attempt at coiling failed, and in 62%, there were anatomical contra- indications to coiling. The authors concluded that the two major morphologic features that would predicate that an MCA aneurysm was unsuitable for endovascular therapy were a dome/neck ratio of 1.5 or less and an arterial branch originating from the aneurysmneck. Although coil technol- ogy has rapidly progressed since that first report by Regli et al., these angioanatomical features still have a role in determining the success of endovascular therapy. In another
detected when she was being evaluated for possible stroke due to transient right facial droop. On examination, she was alert, oriented, and had no neurologic deficits. CT scan did not show any hemorrhage. Digital subtraction angiography demonstrated a bilobed aneurysmmeasuring 9x7 mmwith a 4 mmwide neck located along the pre-bifurcationM1 seg- ment of M1. On close examination and on 3D reconstruction, a small perforator was noted to arise from the neck of the aneurysm. At surgery, the aneurysm showed areas of ath- erosclerosis and two blebs on the dome suggestive of silent bleeds in the past. The perforator was seen to arise from the neck of the aneurysm on the medial side. The aneurysm was dissected from the surrounding parenchyma to which it was attached, and the perforator located medial to the aneurysm was dissected. A 7 mm curved clip was applied across the neck of the aneurysm not incorporating the ori- gin of the perforator artery. Then the aneurysm dome was gently coagulated to shrink the aneurysm. Since the neck was atherosclerotic, a second clip was applied to reinforce the first clip. Postoperative angiography showed complete obliteration of the aneurysm and good filling of the distal vasculature. The perforator vessel was seen filling well in the angiogram. At two-years follow-up, the patient is doing well and has returned to work (Figure 1 and 2). Figure 2: Shows the pictorial representation of the method of aneurysm clipping. The clips have spared the origin of the perforator artery.
164 J La State Med Soc VOL 166 July/August 2014
Made with FlippingBook - Online catalogs