Early exposure of the dorsal surface of M1 segment via the distal transsylvian approach for clipping of anteroinferior-projecting middle cerebral artery bifurcation aneurysms

Kitiporn Sriamornrattanakul; Nasaeng Akharathammachote; Somkiat Wongsuriyanan

doi:10.4103/ajns.ajns_275_21

Asian Journal of Neurosurgery, Inhaltsverzeichnis

CC BY-NC-ND 4.0 · Asian J Neurosurg 2021; 16(04): 797-804
DOI: 10.4103/ajns.ajns_275_21

Original Article

Early exposure of the dorsal surface of M1 segment via the distal transsylvian approach for clipping of anteroinferior-projecting middle cerebral artery bifurcation aneurysms

Kitiporn Sriamornrattanakul

Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok

,

Nasaeng Akharathammachote

Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok

,

Somkiat Wongsuriyanan

Department of Surgery, Division of Neurosurgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok

› Institutsangaben

Abstract

Background: Middle cerebral artery bifurcation (MCAB) aneurysms are common intracranial aneurysms. Anteroinferior-projecting MCAB aneurysms, with the M1 segment usually embedded into the deep part of the Sylvian fissure, cause some surgical challenges. The distal transsylvian approach (DTSA) allows M1 exposure from the dorsal surface for proximal control in the early step. Therefore, this study aimed to demonstrate the efficacy and safety of DTSA for clipping anteroinferior-projecting MCAB aneurysms. Materials and Methods: Among 97 patients with MCA aneurysms, 13 with anteroinferior-projecting MCAB aneurysms who underwent aneurysm clipping via the DTSA between June 2018 and January 2021 were retrospectively evaluated for the aneurysm obliteration rate, surgical complications, and outcomes. Results: Ten patients (76.9%) had ruptured MCAB aneurysms and three (23.1%) had incidentally discovered unruptured MCAB aneurysms. Favorable outcome was achieved in 100% of patients with good grade. The complete aneurysm obliteration rate was 100% without intraoperative lenticulostriate artery injury. Twelve (92.3%) patients had early identified distal M1 segment for proximal control, and one (7.7%) patient had premature rupture of aneurysm that achieved favorable outcome at 3 months postoperatively. Difficult M1 exposure and premature rupture occurred in the patient with MCAB located above the Sylvian fissure line. Permanent postoperative neurological deficit was detected in one patient due to severe vasospasm. Conclusions: DTSA, which simplify the early exposure of the dorsal surface of distal M1, is safe and effective for clipping anteroinferior-projecting MCAB aneurysms without extensive Sylvian fissure dissection. High-positioned MCAB requires careful dissection of the aneurysm neck with consideration of tentative clipping preparation.

Key-words:

Anteroinferior-projecting aneurysm - distal transsylvian approach - middle cerebral artery aneurysm - middle cerebral artery bifurcation aneurysm

Volltext

Referenzen

References
1 Dashti R, Hernesniemi J, Niemelä M, Rinne J, Porras M, Lehecka M, et al. Microneurosurgical management of middle cerebral artery bifurcation aneurysms. Surg Neurol 2007;67:441-56.
2 Heros RC, Fritsch MJ. Surgical management of middle cerebral artery aneurysms. Neurosurgery 2001;48:780-5.
3 Ulm AJ, Fautheree GL, Tanriover N, Russo A, Albanese E, Rhoton AL Jr., et al. Microsurgical and angiographic anatomy of middle cerebral artery aneurysms: Prevalence and significance of early branch aneurysms. Neurosurgery 2008;62:344-52.
4 Alreshidi M, Cote DJ, Dasenbrock HH, Acosta M, Can A, Doucette J, et al. Coiling versus microsurgical clipping in the treatment of unruptured middle cerebral artery aneurysms: A meta-analysis. Neurosurgery 2018;83:879-89.
5 Berro DH, L'Allinec V, Pasco Papon A, Emery E, Berro M, Barbier C, et al. Clip first policy versus coil first policy for the exclusion of middle cerebral artery aneurysms. J Neurosurg 2020;133:1124-31.
6 Darsaut TE, Keough MB, Sagga A, Chan VK, Diouf A, Boisseau W, et al. Surgical or Endovascular management of middle cerebral artery aneurysms: A randomized comparison. World Neurosurg 2021;149:e521-34.
7 Toccaceli G, Diana F, Cagnazzo F, Cannizzaro D, Lanzino G, Barbagallo GM, et al. Microsurgical clipping compared with new and most advanced endovascular techniques in the treatment of unruptured middle cerebral artery aneurysms: A meta-analysis in the modern era. World Neurosurg 2020;137:451-64.e1.
8 Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol 1975;3:7-14.
9 Pritz MB, Chandler WF. The transsylvian approach to middle cerebral artery bifurcation/trifurcation aneurysms. Surg Neurol 1994;41:217-9.
10 Maekawa H, Hadeishi H. Venous-preserving sylvian dissection. World Neurosurg 2015;84:2043-52.
11 Muhammad S, Tanikawa R, Lawton M, Regli L, Niemelä M, Korja M. Microsurgical dissection of Sylvian fissure-short technical videos of third generation cerebrovascular neurosurgeons. Acta Neurochir (Wien) 2019;161:1743-6.
12 Hafez A, Buçard JB, Tanikawa R. Integrated multimaneuver dissection technique of the sylvian fissure: Operative nuances. Oper Neurosurg (Hagerstown) 2017;13:702-10.
13 Dimitriadis S, Qeadan F, Taylor CL, Yonas H, Carlson AP. Middle cerebral artery aneurysm “Neck Overhang": Decreased postclipping residual using the intersecting clipping technique. Oper Neurosurg (Hagerstown) 2018;15:440-6.
14 Ishikawa T, Nakayama N, Moroi J, Kobayashi N, Kawai H, Muto T, et al. Concept of ideal closure line for clipping of middle cerebral artery aneurysms--technical note. Neurol Med Chir (Tokyo) 2009;49:273-7.
15 Ota N, Tanikawa R, Noda K, Tsuboi T, Kamiyama H, Tokuda S. The efficiency of the new Yasargil titanium fenestrated mini-clips for ideal clipping of a cerebral aneurysm. Surg Neurol Int 2015;6:S553-9.
16 Xin WQ, Xin QQ, Yang XY. Meta-analysis of clipping versus coiling for the treatment of unruptured middle cerebral artery aneurysms: Direct comparison of procedure-related complications. Neuropsychiatr Dis Treat 2019;15:3387-95.
17 Nussbaum ES, Madison MT, Goddard JK, Lassig JP, Kallmes KM, Nussbaum LA. Microsurgical treatment of unruptured middle cerebral artery aneurysms: A large, contemporary experience. J Neurosurg 2019;130:1498-504.
18 Sturiale CL, La Rocca G, Puca A, Fernandez E, Visocchi M, Marchese E, et al. Minipterional Craniotomy for Treatment of Unruptured Middle Cerebral Artery Aneurysms. A Single-Center Comparative Analysis with Standard Pterional Approach as Regard to Safety and Efficacy of Aneurysm Clipping and the Advantages of Reconstruction. Acta Neurochir Suppl 2017;124:93-100.
19 Elsharkawy A, Niemelä M, Lehečka M, Lehto H, Jahromi BR, Goehre F, et al. Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms. Acta Neurochir (Wien) 2014;156:17-25.
20 Di Bonaventura R, Sturiale CL, Latour K, Mazzucchi E, Marchese E, Albanese A. Comparison between minipterional craniotomy associated with focused sylvian fissure opening and standard pterional approach with extended Sylvian fissure dissection for treatment of unruptured middle cerebral artery aneurysms. World Neurosurg 2021;146:e1293-300.