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The combined treatment of stenting and surgery in a giant unruptured aneurysm of the middle cerebral artery.

Skrap M, Petralia B, Toniato G - Surg Neurol Int (2015)

Bottom Line: A 51-year-old male presented with a sudden onset of moderate left hemiparesis and dysarthria.Two weeks later, the patient underwent the positioning of an Enterprise stent and inside this, a flow diverter Silk stent.The combined placement of the stents allowed safe and successful surgical dissection of the M2 branches and clipping of the aneurysm without interrupting the blood flow.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Udine University-Hospital P. le S. Maria della Misericordia 15, 33100, Udine, Italy.

ABSTRACT

Background: This case study reports on a combined therapy of stenting and surgery for a giant unruptured middle cerebral artery (MCA) aneurysm with the aim of preserving the patency of the vessel during surgery.

Case description: A 51-year-old male presented with a sudden onset of moderate left hemiparesis and dysarthria. Neuro-radiological evaluations showed a giant right unruptured MCA aneurysm without subarachnoid hemorrhage (SAH). The cerebral angiography confirmed the presence of such an aneurysm producing compression of both M2 branches with consequent slowing of the blood flow. Two weeks later, the patient underwent the positioning of an Enterprise stent and inside this, a flow diverter Silk stent. They were placed across the aneurysm and in one of the two M2 branches with the aim of protecting them during surgical manipulation. The patient went immediately to surgery, where the aneurysm was resected and both M2 branches decompressed.

Conclusion: The combined placement of the stents allowed safe and successful surgical dissection of the M2 branches and clipping of the aneurysm without interrupting the blood flow.

No MeSH data available.


Related in: MedlinePlus

(a,b) The M2 inferior branch was sharply dissected from the wall of the giant aneurysm with a microblade, the vessel kept his steadiness facilitating the dissection and the branch of the MCA maintained the shape thanks to the Silk stent (b, black continued arrow) and the Enterprise stent (b, black interrupted arrow). (c) The dissection of the M2 superior branch with the exposure of adequate working-space around neck aneurysm for clipping. (d) Note the clipping of the aneurysm with three clips and patency of the protected neck
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Figure 4: (a,b) The M2 inferior branch was sharply dissected from the wall of the giant aneurysm with a microblade, the vessel kept his steadiness facilitating the dissection and the branch of the MCA maintained the shape thanks to the Silk stent (b, black continued arrow) and the Enterprise stent (b, black interrupted arrow). (c) The dissection of the M2 superior branch with the exposure of adequate working-space around neck aneurysm for clipping. (d) Note the clipping of the aneurysm with three clips and patency of the protected neck

Mentions: On the day of surgery under general anesthesia in the radiology unit, an Enterprise stent (4.5 × 37 mm) (Cordis Neurovascolar, Miami Lakes, Florida, USA) was first placed from the right carotid dichotomy to the proximal M2 segment of the inferior trunk. Afterwards a flow diverter Silk stent (2.5 × 15 mm) (Balt, Montmorency, France) from the distal M1 segment to the proximal M2 segment of the inferior trunk was placed to complete the coverage of the aneurysmal neck. No stent was placed in the M2 superior thinner trunk of the right MCA. At the end of the endovascular procedure, an angiogram was performed, which showed a major staunching of blood within the sac, patency of the MCA, and the correct position of both stents [Figure 3]. At this point, the patient was moved to the neurosurgical operating room, where a standard pterional approach was performed. Once the sylvian fissure was opened, the aneurysm was immediately visible. Both the M2 trunks of the MCA were seen firmly adhered to the sac. The inferior trunk was larger and the flow diverter Silk stent was visible through the transparency of the arterial wall. Stenting had made the vessel stiffer [Figure 4a and b], easing significantly surgical manipulation during the dissection and also preventing arterial spasms. After freeing the M2 superior trunk [Figure 4c], the aneurysmal neck has been exposed and multiple clips were applied. Because of the consistency of the neck, the first clip tended to slip on the neck, wich in effect was protected by the stent. Three clips and the opening of the aneurysm were necessary to collapse the sac, which was then resected [Figure 4d]. Despite the previous stenting, abundant bleeding occurred during the emptying of the sac. As expected, the patency of the vessels ramained protected by the stents during the entire surgical phase.


The combined treatment of stenting and surgery in a giant unruptured aneurysm of the middle cerebral artery.

Skrap M, Petralia B, Toniato G - Surg Neurol Int (2015)

(a,b) The M2 inferior branch was sharply dissected from the wall of the giant aneurysm with a microblade, the vessel kept his steadiness facilitating the dissection and the branch of the MCA maintained the shape thanks to the Silk stent (b, black continued arrow) and the Enterprise stent (b, black interrupted arrow). (c) The dissection of the M2 superior branch with the exposure of adequate working-space around neck aneurysm for clipping. (d) Note the clipping of the aneurysm with three clips and patency of the protected neck
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4418101&req=5

Figure 4: (a,b) The M2 inferior branch was sharply dissected from the wall of the giant aneurysm with a microblade, the vessel kept his steadiness facilitating the dissection and the branch of the MCA maintained the shape thanks to the Silk stent (b, black continued arrow) and the Enterprise stent (b, black interrupted arrow). (c) The dissection of the M2 superior branch with the exposure of adequate working-space around neck aneurysm for clipping. (d) Note the clipping of the aneurysm with three clips and patency of the protected neck
Mentions: On the day of surgery under general anesthesia in the radiology unit, an Enterprise stent (4.5 × 37 mm) (Cordis Neurovascolar, Miami Lakes, Florida, USA) was first placed from the right carotid dichotomy to the proximal M2 segment of the inferior trunk. Afterwards a flow diverter Silk stent (2.5 × 15 mm) (Balt, Montmorency, France) from the distal M1 segment to the proximal M2 segment of the inferior trunk was placed to complete the coverage of the aneurysmal neck. No stent was placed in the M2 superior thinner trunk of the right MCA. At the end of the endovascular procedure, an angiogram was performed, which showed a major staunching of blood within the sac, patency of the MCA, and the correct position of both stents [Figure 3]. At this point, the patient was moved to the neurosurgical operating room, where a standard pterional approach was performed. Once the sylvian fissure was opened, the aneurysm was immediately visible. Both the M2 trunks of the MCA were seen firmly adhered to the sac. The inferior trunk was larger and the flow diverter Silk stent was visible through the transparency of the arterial wall. Stenting had made the vessel stiffer [Figure 4a and b], easing significantly surgical manipulation during the dissection and also preventing arterial spasms. After freeing the M2 superior trunk [Figure 4c], the aneurysmal neck has been exposed and multiple clips were applied. Because of the consistency of the neck, the first clip tended to slip on the neck, wich in effect was protected by the stent. Three clips and the opening of the aneurysm were necessary to collapse the sac, which was then resected [Figure 4d]. Despite the previous stenting, abundant bleeding occurred during the emptying of the sac. As expected, the patency of the vessels ramained protected by the stents during the entire surgical phase.

Bottom Line: A 51-year-old male presented with a sudden onset of moderate left hemiparesis and dysarthria.Two weeks later, the patient underwent the positioning of an Enterprise stent and inside this, a flow diverter Silk stent.The combined placement of the stents allowed safe and successful surgical dissection of the M2 branches and clipping of the aneurysm without interrupting the blood flow.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Udine University-Hospital P. le S. Maria della Misericordia 15, 33100, Udine, Italy.

ABSTRACT

Background: This case study reports on a combined therapy of stenting and surgery for a giant unruptured middle cerebral artery (MCA) aneurysm with the aim of preserving the patency of the vessel during surgery.

Case description: A 51-year-old male presented with a sudden onset of moderate left hemiparesis and dysarthria. Neuro-radiological evaluations showed a giant right unruptured MCA aneurysm without subarachnoid hemorrhage (SAH). The cerebral angiography confirmed the presence of such an aneurysm producing compression of both M2 branches with consequent slowing of the blood flow. Two weeks later, the patient underwent the positioning of an Enterprise stent and inside this, a flow diverter Silk stent. They were placed across the aneurysm and in one of the two M2 branches with the aim of protecting them during surgical manipulation. The patient went immediately to surgery, where the aneurysm was resected and both M2 branches decompressed.

Conclusion: The combined placement of the stents allowed safe and successful surgical dissection of the M2 branches and clipping of the aneurysm without interrupting the blood flow.

No MeSH data available.


Related in: MedlinePlus