Bypass Surgeries in the Treatment of Cerebral Aneurysms

During surgery for cerebral aneurysm, revascularization techniques are occasionally needed to (1) treat an aneurysm (trapping or flow alteration); (2) preserve blood flow during temporary parent artery occlusion (insurance); and (3) repair accidentally injured vessels (troubleshooting). Herein we present our surgical case experiences.

Revascularization modalities were employed in 33 (7.6 %) of 452 cases of surgically treated aneurysms. The aneurysm locations and associated required bypass procedures were: (1) 7 middle cerebral artery (MCA) aneurysms with 7 superficial temporal artery (STA)-MCA bypass procedures; (2) 10 internal carotid artery (ICA) aneurysms with 9 high-flow and 1 STA-MCA procedures; (3) 10 vertebro-basilar artery aneurysms with 2 high-flow, 6 occipital artery (OA)-posterior ICA, and 1 STA-superior cerebellar artery (SCA) procedures; (4) 1 posterior cerebral artery (PCA) aneurysm with OA-PCA bypass; and (5) 5 anterior cerebral artery aneurysms with 4 A3-A3 and 1 A3-STA-A3 procedure. Curative bypasses for aneurysmal treatment, temporary bypasses, and troubleshooting procedures were performed in 25, 3, and 5 cases, respectively.

Among the 26 aneurysms treated via curative bypass, 16 aneurysms that were trapped or clipped using revascularization techniques had better outcomes (no aneurysmal rupture and 1 perforator infarction), whereas among the 10 aneurysms that could not be trapped or clipped and were thereby treated via flow alteration (e.g., bypass plus proximal artery clipping), 2 developed symptomatic infarction and 2 exhibited aneurysmal rupture after partial thrombosis. Patients whose bypass procedures were used for temporary parent artery occlusion (insurance) or troubleshooting had no complications.

Complex aneurysm clipping or trapping using bypass techniques yielded good results. In particular, perforator vessel ischemia still requires resolution. Flow alteration techniques leading to aneurismal thrombosis carried the risks of ischemic and hemorrhagic complications when applied to intracranial aneurysms. Bypasses for temporary use or troubleshooting were quite effective.