Trapping and Extra-intracranial Bypass for Double Giant Aneurysms in Series with Progressive Stroke Symptomatology

Aims: Complex middle cerebral artery (MCA) aneurysms are defined as having large (10–24 mm) or giant (≥25 mm) size or nonsaccular morphology. Patients with complex MCA aneurysms can present with intracranial hemorrhage, mass effects, and, much rarely, with epilepsy or cerebral ischemia. They have high mortality rate of 65 to 85% within 2 years. We report a case of a 27-year-old male suffering of a double giant MCA aneurysm in series with a progressive stroke symptomatology. Patient Case: The patient was admitted in ER with partial left hemiparesis. CTA, MR, and DSA was performed and a double complex fusiform and saccular in series (20 × 23 × 22 and 42 × 37 × 28 mm) leading to intermittent thromboembolic events was discovered. In the following day, the patient presented a worsening of neurological motor deficits of the left side, with diffusion restriction in MR due to not only compression but also embolic events. Therefore, the patient was put under aspirin and liquemin therapy. Temporal partial lobectomy with trapping of the aneurysm and extra-intracranial bypass, from superficial temporal artery on the M2 distal to the aneurysms, was performed. Intraoperative sensory-evoked potential (SEP) and motor-evoked potential (MEP) were stable. Patency of extra-intracranial bypass was confirmed by indocyanine fluorescence intraoperative angiography and by Doppler flow measurements. An extradural ICP monitor was positioned. After surgery patient was admitted in intensive care. After 12 hours, ICP increased over 20 and a CT showed a right brain swelling with midline shift caused by a worsening of the ischemia in MCA territory. A right decompressive craniectomy was immediately performed and the bypass was confirmed patent with Doppler flow measurements. Further increase in ICP was noted, CT showing an important brain swelling and uncal herniation. A right frontotemporal lobectomy was performed. After 10 days, sedation was stopped and the patient gradually recovered. Three weeks later, the patient presented an increasing hydrocephalus treated with ventriculoperitoneal shunt. After few days, a cranioplasty was realized. Patient remained under aspirin throughout the complete hospitalization and surgeries. Patient was discharge to rehabilitation department presenting GCS 15, mild left hemiparesis, and moderate swallow deficits (NIHSS 3). Conclusions: Transient preoperative and postoperative deterioration was due to transient thromboembolic and compressive events. Maintaining EC-IC bypass in patient with craniectomy and cranioplasty is possible. In what grade the EC-IC bypass helped for the reversal of neurological deficits remains to be proven on the long run with further MR imaging.

References

References

1 Zhu W, Liu P, Tian Y, et al. Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies. Acta Neurochir (Wien) 2013;155(8):1481–1491

2 Choi IS, David C. Giant intracranial aneurysms: development, clinical presentation and treatment. Eur J Radiol 2003;46(3):178–194