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Extracranial-Intracranial Bypass and Vessel Occlusion for the Treatment of Unclippable Giant Middle Cerebral Artery Aneurysms

Kalani, M. Yashar S. MD, PhD; Zabramski, Joseph M. MD; Hu, Yin C. MD; Spetzler, Robert F. MD

doi: 10.1227/NEU.0b013e3182804381
Research-Human-Clinical Studies

BACKGROUND: Giant middle cerebral artery (MCA) aneurysms pose management challenges.

OBJECTIVE: To review the outcomes of patients with giant MCA aneurysms not amenable to clipping or vessel reconstruction treated with extracranial-intracranial (EC-IC) bypass and vessel sacrifice.

METHODS: We retrospectively reviewed a database of aneurysms treated at our institution between 1983 and 2011.

RESULTS: Sixteen patients (11 males, 5 females) were identified. There were 10 saccular, 4 fusiform, and 2 serpentine aneurysms. The aneurysms predominantly involved the M1 segment in 5 cases, M2 in 9 cases, and both M1 and M2 in 2 cases. The EC-IC bypasses performed included 13 superficial temporal artery-MCA, 1 saphenous vein graft-MCA, and 2 radial artery grafts-MCA. The postoperative bypass patency rate was 93.8% (15/16). There were 3 cerebrovascular accidents (18.8%), but no perioperative deaths (0% mortality). The mean follow-up was 58.4 months (range, 1-265; median, 23.5 months). In 75% (12/16) of cases the aneurysms were occluded successfully. A small residual was noted in 3 cases with the use of this treatment strategy, and they were re-treated. In a fourth case treated with partial distal occlusion, reduced flow through the aneurysm was noted postoperatively, but the patient did not undergo further treatment. The mean modified Rankin scale and mean Glasgow Outcome Scale scores at last follow-up were 1.6 (range, 1-4; median, 1) and 4.8 (range, 3-5; median, 5), respectively.

CONCLUSION: Giant MCA aneurysms are challenging lesions. EC-IC bypass with parent vessel occlusion can provide a durable form of treatment with acceptable rates of morbidity and mortality.

ABBREVIATIONS: CVA, cerebrovascular accidents

EC-IC, extracranial-intracranial

GOS, Glasgow Outcome Scale

MCA, middle cerebral artery

RAG, radial artery graft

SAH, subarachnoid hemorrhage

SVG, saphenous vein graft

STA, superficial temporal artery

Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona

Correspondence: Robert F. Spetzler, MD, c/o Neuroscience Publications; Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ 85013. E-mail:

Received June 29, 2012

Accepted November 07, 2012

Copyright © by the Congress of Neurological Surgeons