Download Prof. Dr. Hussein Mahmoud Khairy Prof. Dr. Essam M. Rashad Al

MANAGEMENT OF MIDDLE CEREBRAL ARTERY
ANEURYSMS
Essay
Submitted for Partial Fulfillment of Master Degree (M.Sc.) in
General Surgery
By
Mostafa Mohamed Essayed Mohamed Atteya
M.B.B.Ch.
Supervisors
Prof. Dr. Hussein
Mahmoud Khairy
Professor of General Surgery
Faculty of Medicine
Cairo University
Prof. Dr. Essam
M. Rashad Al-Gahawy
Professor of Neurosurgery
Faculty of Medicine
Cairo University
Dr. AMR Abdullah Kamal AL-SAMMAN
Lecturer of Neurosurgery
Faculty of Medicine
Cairo University
Faculty of Medicine
Cairo University
2009
‫ﺒﺴﻡ ﺍﷲ ﺍﻟﺭﺤﻤﻥ ﺍﻟﺭﺤﻴﻡ‬
‫ﻭﻗل ﺭﺏ ﺯﺩﻨﻲ ﻋﻠﻤﺎ‬
‫ﺼﺩﻕ ﺍﷲ ﺍﻟﻌﻅﻴﻡ‬
ACKNOWLEDGEMENT
First of all; I thank ALLAH who helped me to bring this work to light
I wish to express my deepest gratitude to Prof. Dr. Hussein
Mahmoud Khairy, Professor of General Surgery Faculty of
Medicine, Cairo University ;
for his kind supervision and valuable
advice, without his support and wise council, this work wouldn't have
been completed.
My special thanks and deepest appreciation to Prof. Dr. Essam
M. Rashad Al-Gahawy, Professor of Neurosurgery, Faculty of
Medicine, Cairo University, who generously offered a lot of his precious
time and interest. His encouragement and guidance were a real help to
accomplish my task.
I'm also deeply grateful to Dr. Amr Abdullah Kamal
Al-Samman, Lecturer of Neurosurgery, Faculty of Medicine, Cairo
University for his kind supervision, indispensable remarks, continuous
support, he offered me most of his effort as well as deep experience.
ABSTRACT
The middle cerebral artery represents one of the commonest sites of
intracranial aneurysms especially at its bifurcation.
Clinical diagnosis depends in most cases on the development of
subarachnoid hemorrhage (S.A.H) and its complications after aneurysmal
rupture.
Radiologic studies play an important rule in the diagnosis of
intracranial aneurysms and S.A.H. that's based on two steps:
1. Diagnosis of SAH that depends mainly on brain C.T.
2. Diagnosis of the aneurysm: four vessel angiography is the corner stone
for its diagnosis.
Treatment is based on many lines including:
1. Medical treatment for: SAH, its complications especially vasospasm and
treatment of the medical problems especially hypertension.
2. Surgical treatment: based on clipping of the aneurysms with aneurysmal
clips.
3. Advanced endovascular techniques especially by aneurysmal occlusion
by Gugulielmi detachable coils.
The final step in the treatment lines is patient rehabilitation
Key Words:
(Aneurysm–subarachnoid hemorrhage-clipping-Guglielmi detachable coilembolization -middle cerebral artery).
Dedication
Dedicated to my wife and my coming kid who gave
me unbelievable support all the time without which,
I couldn't have made it.
Dedicated also to my mother and my brother Dr.
Ashraf Essayed who supported me by all means,,
they gave me too much and received too little.
Specially dedicated to my dear Professor Dr. Saudi
A Zamzam who teached us to respect ourselves and
our career and gave us energetic support and experience.
CONTENTS
Page
Acknowledgement………………………………………………….
Abstract……………………………………………………………..
List of Abbreviation………………………………………………..
List of Tables………………………………………………………..
List of Figures………………………………………………………
Introduction and Aim of the Work………………………………...
Review of Literature:
• Anatomy…………………………………………………………..
• Pathology………………………………………………………….
• Clinical Presentation……………………………………………..
• Investigation………………………………………………………
• Management………………………………………………………
• Surgical Management……………………………………………..
• Endovascular Management………………………………………..
Summary and Conclusion………………………………………….
References……………………………………………………………
Arabic Summary……………………………………………………
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LIST OF ABBREVIATIONS
ACA
ACoA
AComA
ADPKD
ANF
ASyP
AVM
C4
CCA
CTA
DMCA
3D-RA
DSA
DSA
ED
EVT
FAST
FLAIR
GDCs
HCP
HHH
ICA
ICH
ICP
ISAT
ISUIA
IVH
LP
M1
M1A
M2
M3
M4
MAP
: Anterior cerebral artery
: Anterior communicating artery
: Anterior communicating artery
: Autosomal dominant polycystic kidney disease
: Atrial natriuretic factor
: Anterior sylvian point
: Arteriovenous malformation
: Supraclinoid portion of internal carotid artery
: Conventional catheter angiography
: Computed tomography angiography
: Duplication of the middle cerebral artery
: 3-dimensional rotational angiography
: Digital subtraction angiography
: Digital subtraction angiography
: Emergency department
: Endovascular treatment
: Flow-assisted surgical technique
: Fluid-attenuated inversion recovery
: Guglielmi detachable coils
: Hydrocephalus
: Hypertensive, hypervolemic, and hemodilutional
: Internal carotid artery
: Intracerebral hemorrhage
: Intracranial pressure
: International Subarachnoid Aneurysm Trial
: International Study of Unruptured Intracranial Aneurysms
: Intraventricular hemorrhage
: Lumbar puncture
: Sphenoidal segment of middle cerebral artery
: Proximal MCA aneurysm
: Insular segment of middle cerebral artery
: Opercular segment of middle cerebral artery
: Cortical segment of middle cerebral artery
: Reaches mean arterial pressure
MbifA
MCA
MdistA
MRA
PCoA
PET
RIAs
SAH
SDH
SIADH
SLE
SPECT
SSRIs
TCD
UIAs
VBA
VMRM
WFNS
XeCT
: MCA bifurcation aneurysm
: Middle cerebral artery
: Distal MCA aneurysm
: Magnetic resonance angiography
: Posterior communicating artery
: Emission tomography
: Ruptured intra-cranial aneurysms
: Subarachnoid hemorrhage
: Subdural hematoma
: Syndrome of inappropriate secretion of antidiuretic hormone
: Systemic lupus erythematosus
: Single-photon emission computed tomography
: Selective serotonin reuptake inhibitors
: Transcranial Doppler ultrasonography
: Unruptured intra-cranial aneurysms
: Vertebrobasilar artery
: Virtual MR microscopy
: World Federation of Neurosurgical Societies
: Xenon-CT
LIST OF TABLES
Table
Title
1
Overall risk of bleeding at 1 year posttreatment in patients
with unruptured aneurysms………………………………………
Yearly and 5-year cumulative rupture rates in unruptured
aneurysms according to the ISUIA………………………………
Relationship between size and location of aneurysms and the
annual and cumulative risk of rupture after 5 years……………
5-Year cumulative rupture rates of intracranial aneurysms……
CTA compared with DSA………………………………………..
Frequency of occurrence of risk factors………………………….
Anatomical result in relation to aneurysm size…………………..
Procedure-related complications…………………………………
2
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8
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LIST OF FIGURES
Fig.
Title
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The Sylvian fissure……………………………………………….
The Sylvian fissure and insula…………………………………..
Relation of MCA to the insula and Sylvian fissure……………...
Superolateral view of the right insula……………………………
Anterior perforated substance and Sylvian fissure……………….
Middle cerebral aneurysms, morbid anatomy……………………
Segments of middle cerebral artery………………………………
Different views of the cerebral arteries…………………………..
The territory of the middle cerebral artery……………………….
Duplicated MCA………………………………………………...
Outcome of SAH…………………………………………………
Neurologic complications after SAH…………………………….
The Aspect Ratio…………………………………………………
Computed tomography scan demonstrating SAH………………..
Xenon CT………………………………………………………..
angiogram showing Lt. MCA bifurcation aneurysm…………….
4 vessel angiogram showing giant Lt. MCA aneurysm………….
T2WI MRI and CT brain………………………………………...
partially thrombosed large MdistA………………………………
saccular aneurysm at the trifurcation of Lt. MCA……………….
MCA aneurysm initially missed by CTA……………………….
Preoperative CT angiography……………………………………
Postoperative angiography……………………………………….
Coronal and 3D CTA of a MdistA……………………………….
CT angiography of a right MCA aneurysm……………………..
MRA demonstrates an unruptured distal MCA aneurysm……….
Transcranial Doppler changes in vasospasm from baseline……..
Flow assisted technique………………………………………….
Xanthochromia…………………………………………………..
Techniques for surgical treatment of aneurysms………………...
Effect of head rotation in pterional approach…………………….
Typical microsurgical exposure………………………………….
Intra-operative view of left MCA in the Sylvian fissure…………
3'
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Surgical view of MCA…………………………………………..
81'
Schematic drawing of Modified Pterional Approach……………. 83'
Aneurysm of the proximal (trunk) MCA………………………... 87'
Intra-operative view of right insular-type MbifA………………..
89'
Saccular MCA aneurysm embedded in temporal lobe…………... 91'
Inadequate MbifA clipping……………………………………… 91''
After clip readjustment………………………………………….. 91''
Intra-operative view of the left distal Sylvian fissure…………… 96'
Endovascular treatment concepts………………………………... 110'
Deposition of liquid embolic agent (Onyx)……………………... 111'
Coil embolization………………………………………………... 114'
Adequate follow-up angiogram…………………………………. 114'
Follow-up angiogram with opening at the base…………………. 114''
Follow-up angiogram with coil extrusion……………………….. 114''
Adequate endovascular intervention…………………………….. 116'
Introduction & Aim
1
Introduction and Aim
INTRODUCTION AND AIM OF THE WORK
Aneurysms of the middle cerebral artery (MCA) are common,
representing approximately 20% of all intracranial aneurysms, causing one-fifth
of all aneurysmal subarachnoid hemorrhage (SAH) and occur in three-fourths of
all patients with multiple intracranial aneurysms (Benitez et al., 2004).
Digital subtraction angiography (DSA) is still the present gold standard in
many centers. Multislice helical computed tomography angiography (CTA) is
the primary modality in many centers for several reasons: non-invasive and
quick imaging; comparable sensitivity and specificity to DSA in aneurysms
larger than 2 mm (Wintermark et al., 2006).
Obliteration of an aneurysm (ruptured or unruptured) with coiling or
clipping is a matter of much controversy. Currently, data suggest that, whereas
coiling is somewhat safer than clipping for both ruptured and unruptured
aneurysms, at least in the acute perioperative period, clipping is slightly more
durable (Johnston, 2001).
Controversy also exists between so-called early surgery (generally, but
not precisely defined as within 48-96 h post- SAH) and late surgery (usually
>10-14 d post-SAH).
MCA aneurysms can be surgically approached with one of three
techniques. The first is the proximal Sylvian fissure approach, which involves
splitting the fissure in a medial-to-lateral direction. The second technique is the
distal Sylvian fissure approach, which involves splitting the fissure laterally and
following an insular segment branch (M2) proximally to the aneurysm. The
third, the transcortical superior temporal gyrus approach involves subpial
dissection with exposure of peripheral MCA branches and following of those
branches proximally, similarly to the distal Sylvian fissure approach (Ogilvy et
al., 1995).
Until the 1970s, clipping and wrapping were the main options for the
treatment of intracranial aneurysms. In the 1990s, the use of Guglielmi
detachable coils radically changed the surgical approach to intracranial
Introduction & Aim
2
Introduction and Aim
aneurysms, and endovascular treatment became a frequent choice for many
ruptured intracranial aneurysms (Guglielmi et al., 1991).
During recent years, important new endovascular techniques and
materials widened the range of aneurysms susceptible to endovascular treatment.
The balloon remodeling technique, embolization with liquid embolic agents
(such as Onyx), and stent and coil combinations are currently used to treat
complicated aneurysms such as wide-necked, giant, and fusiform aneurysms, as
well as pseudoaneurysms (Alfke et al., 2004).
Recent reports indicated that coiling followed by clot evacuation may be a
less invasive treatment (Jeong et al., 2007).
Exact risks for clipping or coiling an aneurysm are not known and depend
on patient and aneurysm specific factors. Surgeon and institutional volume
likely also plays a role, which has not yet been quantified (Barker, 2003 and
Hoh, 2003).
This work aims at reviewing literature, providing related practical
microsurgical anatomy, pre-operative planning and decision making, and
evaluating current modalities in investigation and management of middle
cerebral artery aneurysms.
Review of Literature
3
Relevant Microsurgical Anatomy
RELEVANT MICROSURGICAL ANATOMY
SYLVIAN FISSURE ANATOMY:
The Sylvian fissure or lateral sulcus is the most identifiable feature of the
superolateral brain surface and constitutes the main microneurosurgical corridor,
given the high frequency of approachable intracranial lesions through this route.
The anterior Sylvian point (ASyP) divides this fissure in its main anterior and
posterior rami (Ribas et al., 2005).
The Sylvian fissure is the most distinct and consistent landmark on the
lateral surface. It is a complex fissure that carries the middle cerebral artery and
its branches and provides a surgical gateway connecting the cerebral surface to
the anterior part of the basal surface and cranial base.
The Sylvian fissure is the deep and prominent cerebral fissure traversing
the inferior and lateral surfaces of the brain and extending from the anterior
perforated substance to the supramarginal gyrus. It separates the frontal and
parietal lobes from the temporal lobe, and the insula forms its floor. The Sylvian
fissure is divided into anterior (stem) and posterior (insulo-opercular)
compartments. The stem originates inferiorly at the anterior perforated substance
located at the level of the ambient gyrus of the uncus and extends laterally
between the orbital gyri and the temporal pole. The average length of the
Sylvian stem measured 39 mm. The temporal incisura and the frontoorbital limb
are two side branches of the Sylvian stem (Yasargil et al., 1984).
As the stem reaches the lateral surface of the brain, it divides into the
horizontal, ascending, and posterior rami; named the confluence of these three
rami the "Sylvian point". The horizontal and ascending rami divide the inferior
frontal gyrus into the pars orbitalis, pars triangularis, and pars opercularis. The
posterior ramus separates the frontal and parietal lobes from the temporal lobe
and forms the Sylvian line, which averaged 75 mm in length. The posterior
ramus is composed of the diagonal sulcus, the anterior and posterior subcentral
sulci, and the terminal ascending and descending limbs, as well as the side
branch of the transverse temporal sulcus. The horseshoe-shaped supramarginal
gyrus drapes over the superior boundary of the posterior ramus (Yasargil et al.,
1999).
Review of Literature
4
Relevant Microsurgical Anatomy
The floor of the Sylvian stem constitutes the preinsular sulcus (Sylvian
vallecula), which corresponds to the anterior perforated substance. The average
length of the preinsular sulcus was 32 mm in the brain specimens. The Sylvian
stem has adapted to the contours of the posterior border of the lesser wing of the
sphenoid bone. The floor of the posterior ramus of the Sylvian fissure is
composed of the insula and postinsular sulcus. The average length of the
postinsular sulcus measured 38 mm (Yasargil et al., 1999).
The Sylvian fissure is not a simple longitudinal cleft as its name implies.
It crosses both the basal and lateral cerebral surface and has a superficial and a
deep part. The superficial part is visible on the surface of the brain and the deep
part, often referred to as the Sylvian cistern, and is hidden below the basal
surface.
The superficial component contains a stem and three rami. The stem runs
in a medial to lateral direction between the frontal and temporal lobes. The
sphenoid ridge projects against the stem of the fissure. The three rami are called
the posterior, anterior ascending, and anterior horizontal rami. The posterior
ramus extends posteriorly lying between the frontal and parietal lobes superiorly
and the temporal lobe inferiorly. The anterior ascending and anterior horizontal
rami divide the inferior frontal gyrus into three parts: the pars orbitalis, pars
triangularis and pars opercularis (Rhoton, 2002).
The deep part of the Sylvian fissure, hidden below the surface, is referred
to as the Sylvian cistern. It is more complex than the superficial part and is
divided into sphenoidal and operculoinsular compartments. The sphenoidal
compartment extends laterally from the cistern around the internal carotid artery,
between the frontal and temporal lobes. The roof of the sphenoidal compartment
is formed by the posterior part of the orbital surface of the frontal lobe and the
anterior perforated substance. The caudate and lentiform nuclei and the anterior
limb of the internal capsule are located above the roof. The floor is formed by
the anterior part of the planum polare, an area free of gyri on the upper temporal
pole, where a shallow cupped trench accommodates the course of the middle
cerebral artery. The anterior segment of the uncus, the site of the amygdala, is
located at the medial part of the floor. The limen insulae, the prominence
overlying the cingulum, a prominent fiber bundle connecting the frontal and