- Department of Neurosurgery, National Brain Aneurysm Center, St. Joseph's Hospital, St. Paul, MN 55102, USA
Department of Neurosurgery, National Brain Aneurysm Center, St. Joseph's Hospital, St. Paul, MN 55102, USA
DOI:10.4103/2152-7806.82991Copyright: © 2011 Nussbaum L. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Nussbaum L, Defillo A, Zelensky A, Nussbaum ES. A short segment intracranial–intracranial jump graft bypass followed by proximal arterial occlusion for a distal MCA aneurysm. Surg Neurol Int 18-Jul-2011;2:98
How to cite this URL: Nussbaum L, Defillo A, Zelensky A, Nussbaum ES. A short segment intracranial–intracranial jump graft bypass followed by proximal arterial occlusion for a distal MCA aneurysm. Surg Neurol Int 18-Jul-2011;2:98. Available from: http://sni.wpengine.com/surgicalint_articles/a-short-segment-intracranial-intracranial-jump-graft-bypass-followed-by-proximal-arterial-occlusion-for-a-distal-mca-aneurysm/
Background:To describe the use of a short segment cortical intracranial–intracranial (IC–IC) bypass for the treatment of a distal middle cerebral artery (MCA) aneurysm.
Case Description:A 54-year-old woman presented with a loss of consciousness followed by multiple seizures and was found to have a partially thrombosed distal MCA aneurysm. This possibly mycotic aneurysm was treated by creating a short segment jump graft between a normal cortical artery and a nearby cortical branch arising from the aneurysmal M3 arterial segment. The bypass allowed for subsequent occlusion of the aneurysmal vessel without ischemic consequence. At surgery, the anterior division of the superficial temporal artery (STA) was exposed and dissected. Intraoperative angiography was utilized to localize a cortical artery arising from the involved segment as well as a nearby cortical artery arising from a distinct, uninvolved MCA branch. A segment of the STA was harvested, and then 10-0 suture was utilized to anastomose this short segment, to both the involved and normal cortical arteries. This created a short jump graft allowing for subsequent sacrifice of the diseased artery. Following surgery, the patient immediately underwent coil embolization of the aneurysm back into the parent artery resulting in local vascular sacrifice. The remainder of the patient's hospital course was uneventful. She was discharged home in good condition.
Conclusions:We suggest that cortical IC–IC bypass followed by endovascular arterial sacrifice as performed in our case represents a simple and safe option for treating unclippable distal MCA aneurysms including mycotic lesions.
Keywords: Intracranial-intracranial bypass, middle cerebral artery, mycotic aneurysm
Mycotic intracranial aneurysms are typically associated with bacterial endocarditis, although other sources of systemic infection can also be responsible.[
A 54-year-old woman presented with sudden-onset loss of consciousness followed by repeated generalized seizures. During ambulance transport, she was drowsy but able to protect her airway. On admission to the National Brain Aneurysm Center, she suffered another seizure. An intravenous anticonvulsant load was administered, and she was emergently intubated. Admission CT-scan revealed a hyperdense 2 × 3 cm2 lesion involving the temporoparietal junction with an associated 7 mm high attenuation nidus at its anterior margin. This lesion was surrounded by vasogenic edema [
A thorough medical evaluation disclosed no evidence of fever, and the white blood cell count and tagged white blood cell exam were unremarkable. Her erythrocyte sedimentation rate was within the normal limit, but her C-reactive protein was elevated. Cardiology consult, chest, and abdominal CT-scan were all noncontributory. It was felt that this lesion most likely represented a mycotic aneurysm, and after combined consultations with the neurovascular and infectious disease services, a decision was made to proceed with treatment of the aneurysm. Careful study and evaluation of the aneurysm outflow revealed important supply to the nondominant motor cortex. Thus, simple sacrifice of the involved arterial segment seemed ill-advised. In addition, it was unclear how straightforward it would be to locate the aneurysm within the sylvian fissure or whether the involved segment could be primarily repaired once identified. Due to the poor caliber of the posterior division STA, a traditional extracranial-intracranial (EC–IC) bypass was not feasible. Therefore, we decided to perform an IC–IC short jump graft bypass in preparation for endovascular sacrifice of the parent vessel related to the aneurysmal segment.
At surgery, the anterior division of the STA was exposed and dissected over an adequate length, and a generous craniotomy was performed. Intraoperative angiography was utilized to localize a cortical artery arising from the involved segment as well as a nearby cortical artery arising from a distinct, uninvolved MCA branch. A segment of the STA was harvested, and then 10-0 suture was utilized to anastomose this short segment to both the involved and normal cortical arteries, both as end-to-side grafts [
Following surgery, the patient was taken directly to the biplane-suite for coil embolization of the parent right MCA-M3 posterior division at the level of the aneurysm [
Mycotic aneurysms may affect any intracranial artery, although the distal MCA territory is the most common location involved.[
The management of these mycotic intracranial aneurysms is highly controversial and depends on multiple factors. Some authors suggest treating unruptured aneurysms with antibiotics and sequential cerebral angiograms.[
Available surgical options for treating these lesions include direct clipping, wrapping, proximal occlusion, trapping, distal revascularization, excision with end-to-end re-anastomosis, or some combination of the above.[
Ruptured and unruptured mycotic aneurysms are potentially lethal intracranial lesions. Management of such aneurysms is complex, and the best outcomes will generally be achieved in experienced centers that can offer endovascular support as well as complex surgical treatments including revascularization techniques. We suggest that cortical IC–IC bypass followed by endovascular arterial sacrifice as performed in our case represents a simple and safe option in this setting.
1. Ausman JI, Handa H, Kikuchi H.editors. Surgical anatomy of the proximal segments of the middle cerebral artery (MCA). Microsurgical Anastomoses from cerebral Ischemia. New York: Igaku-Shoin; 1985. p. 130-2
2. Bohmfalk GL, Story JL, Wissinger JP, Brown WE. Bacterial intracranial aneurysm. J Neurosurg. 1978. 48: 369-82
3. Chun JY, Smith W, Halbach VV, Higashida R, Wilson CB, Lawton MT. Current multimodality management of infectious intracranial aneurysms. Neurosurgery. 2001. 48: 1203-14
4. Clare CE, Barrow DL. Infectious intracranial aneurysm. Neurosurg Clin N Am. 1992. 3: 551-66
5. Davidson P, Robertson DM. A true mycotic (Aspergillus) aneurysm leading to fatal subarachnoid hemorrhage in a patient with hereditary hemorrhagic telangiectasia. Case report. J Neurosurg. 1971. 35: 71-6
6. Di Maio S, Mohr G, Dufour JJ, Albrecht S. Distal mycotic aneurysm of the AICA mimicking intracanalicular acoustic neuroma. Can J Neurol Sci. 2003. 30: 388-92
7. Frazee JG, Cahan LD, Winter J. Bacterial intracranial aneurysms. J Neurosurg. 1980. 53: 633-41
8. Hart RG, Kagan-Hallet K, Joerns SE. Mechanisms of cerebral intracranial hemorrhage in infective endocarditis. Stroke. 1987. 18: 1048-56
9. Horten BC, Abbott GF, Porro RS. Fungal aneurysms of intracranial vessels. Arch Neurol. 1976. 33: 577-9
10. Ito Z. A new technique of intracranial interarterial anastomosis between distal anterior cerebral arteries (ACA) for ACA occlusion and its indication. Neurol Med Chir (Tokyo). 1981. 21: 931-9
11. Kannoth S, Iyer R, Thomas SV, Furtado SV, Rajesh BJ, Kesavadas C. Intracranial infectious aneurysm: Presentation, management and outcome. J Neurol Sci. 2007. 256: 3-9
12. Kannoth S, Thomas SV. Intracranial microbial aneurysm (infectious aneurysm): Current options for diagnosis and management. Neurocrit Care. 2009. 11: 120-9
13. Meyer YJ, Batjer HH. Resolution of a recurrent/residual bacterial aneurysm during antibiotic therapy. Neurosurgery. 1990. 26: 537-9
14. Nakahara I, Taha MM, Higashi T, Iwamuro Y, Iwaasa M, Watanabe Y. Different modalities of treatment of intracranial mycotic aneurysms: Report of 4 cases. Surg Neurol. 2006. 66: 405-9
15. Ojemann RG, Ojemman RG, Ogilvy CS, Crowell RM.editors. Infectious intracranial aneurysms. Surgical Management of Neurovascular Disease. Baltimore: Williams and Wilkins; 1995. p. 368-76
16. Peters PJ, Harrison T, Lennox JL. A dangerous dilemma: Management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis. 2006. 6: 742-8
17. Scotti G, Li MH, Righi C, Simionato F, Rocca A. Endovascular treatment of bacterial intracranial aneurysms. Neuroradiology. 1996. 38: 186-9
18. Smith RR, Parent AD. End-to-end anastomosis of the anterior cerebral artery after excision of a giant aneurysm. J Neurosurg. 1982. 56: 577-80
19. Visudhiphan P, Bunyaratavej S, Khantanaphar S. Cerebral aspergillosis. Report of three cases. J Neurosurg. 1973. 38: 472-6
20. Wajnberg E, Rueda F, Marchiori E, Gasparetto EL. Endovascular treatment for intracranial infectious aneurysms. Arq Neuropsiquiatr. 2008. 66: 790-4
21. Watanabe A, Hirano K, Ishii R. Cerebral Mycotic aneurysm treated with endovascular occlusion: Case report. Neurol Med Chir (Tokyo). 1998. 38: 657-60
22. Yasargil MG.editors. Anastomosis between the anterior cerebral arteries in Microsurgery Applied to Neurosurgery. New York: Academic Press; 1969. p. 115-7
23. Yokoh A, Ausman JI, Dujovny M, Diaz FG, Berman SK, Sanders J. Anterior cerebral artery reconstruction. Neurosurgery. 1986. 19: 26-35