Clip Reconstruction of Recurrent, Previously Coiled MCA Aneurysm with M2-M2 Side-Side Reimplantation

Authors

Visish M. Srinivasan, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Rohin Singh, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Mohamed A. Labib, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.Follow
Stephen Dabrowski, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Redi Rahmani, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Joshua S. Catapano, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.Follow
Christopher S. Graffeo, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.Follow
Michael T. Lawton, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA. Electronic address: Neuropub@barrowneuro.org.Follow

Document Type

Article

Abstract

Fourth-generation bypass techniques are novel constructs that may be useful when standard bypass methods fail. They involve the use of an unconventional (i.e., intraluminal) suturing technique (type 4A) or vascular orientation (type 4B). We report the use of a type 4B fourth-generation reimplantation bypass for treatment of a recurrent middle cerebral artery (MCA) aneurysm. A woman in her mid-60s presented with recurrence of a previously treated unruptured MCA aneurysm. Her aneurysm was partially coiled, and recurrence developed at the base of the coil mass. Informed consent was obtained from the patient. The MCA bifurcation was exposed with a pterional-transsylvian approach (Video 1). The aneurysm fundus was mobilized to visualize the origin at the bifurcation between the middle and frontal trunk of the MCA. Clip reconstruction was attempted via a "picket-fence" technique. Indocyanine green videoangiography revealed occlusion of the middle trunk. The middle trunk was transected and reimplanted to the frontal trunk in end-side fashion, with intraluminal suturing (type 4A bypass). Indocyanine green videoangiography showed no flow because of endothelial damage from the endovascular therapy. The middle trunk was transected off the frontal trunk and diverted to the temporal trunk, where a type 4B side-to-side reimplantation bypass was performed using a longer arteriotomy to maximize the anastomotic area. Patency and aneurysm occlusion were confirmed with Yellow 560 fluorescence. The patient tolerated the procedure well, and no postoperative neurologic deficits were noted. The fourth-generation bypass concepts allow the surgeon to conceive atypical constructs, which are especially useful for troubleshooting challenging revascularization scenarios..

Medical Subject Headings

Humans; Female; Cerebral Revascularization (methods); Indocyanine Green; Intracranial Aneurysm (diagnostic imaging, surgery); Replantation; Surgical Instruments; Middle Cerebral Artery (surgery)

Publication Date

11-1-2022

Publication Title

World neurosurgery

E-ISSN

1878-8769

Volume

167

First Page

8

PubMed ID

35973521

Digital Object Identifier (DOI)

10.1016/j.wneu.2022.08.031

Recommended Citation

Srinivasan, Visish M.; Singh, Rohin; Labib, Mohamed A.; Dabrowski, Stephen; Rahmani, Redi; Catapano, Joshua S.; Graffeo, Christopher S.; and Lawton, Michael T., "Clip Reconstruction of Recurrent, Previously Coiled MCA Aneurysm with M2-M2 Side-Side Reimplantation" (2022). Neurosurgery. 1786.
https://scholar.barrowneuro.org/neurosurgery/1786