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Superior temporal gyrus approach to middle cerebral artery aneurysms: technique and results
Abstract:
Aneurysms of the bifurcation of the middle cerebral artery (MCA) can be approached through a small incision in the anterior portion of the superior temporal gyrus. The pterion and the lateral aspect of the lesser wing of the sphenoid bone are removed. The aneurysm is approached, using microsurgical techniques, by following the main divisions of the MCA to the parent trunk and the base of the aneurysm. Once the parent vessel and the origin of the major divisions are clearly identified, it is usually preferable to dissect and mobilize the entire aneurysmal complex to elucidate the anatomy and prepare the neck for clipping. This approach offers the advantages of minimal brain retraction and minimal manipulation of the main trunk and perforators of the MCA. In addition, it allows a more complete exposure of the aneurysmal complex and facilitates dissection behind the aneurysm, which is more difficult when the aneurysm is approached from the front by opening the sylvian fissure medially to laterally. A potential disadvantage of this method is that proximal control is not obtained until the base of the aneurysm is reached, but this has not been a problem in our experience. Other disadvantages are the need for a slightly larger bone flap and the potentially increased risk of epilepsy. This approach is not suitable when the main trunk of the MCA is short and the aneurysm is in front of the insula. It is also not recommended for the rare cases in which the aneurysm points back over the insula. During a 6-year period, this approach was used in 49 of 58 cases of MCA aneurysm. The only deaths in this group occurred in patients who were in deep coma before operation. Two patients were made worse by operative complications, and 2 more worsened as a result of postoperative vasospasm. There was a significant incidence of thrombophlebitis and pulmonary embolism in this series.
Insights
This study details a microsurgical approach for middle cerebral artery (MCA) aneurysms, offering advantages like minimal brain retraction. The technique proved effective in most cases, with complications primarily in critically ill patients.
Area of Science:
- Neurosurgery
- Vascular Neurosurgery
- Cerebrovascular Surgery
Background:
- Middle cerebral artery (MCA) aneurysms are common and can be life-threatening.
- Surgical approaches aim for safe and effective aneurysm clipping with minimal complications.
Purpose of the Study:
- To evaluate a specific microsurgical approach for MCA bifurcation aneurysms.
- To assess the efficacy and safety of this technique.
Main Methods:
- Microsurgical technique involving a superior temporal gyrus incision and pterional craniotomy.
- Dissection along MCA divisions to the aneurysm base for clipping.
- Mobilization of the aneurysmal complex for clear visualization and preparation.
Main Results:
- The approach was used in 49 of 58 MCA aneurysms over 6 years.
- Complications were mainly observed in patients with pre-operative deep coma.
- No deaths occurred in patients operated on with better pre-operative condition.
Conclusions:
- This approach provides good exposure and minimal brain retraction for MCA aneurysms.
- It is a viable option, though not suitable for all MCA aneurysm locations.
- Careful patient selection is crucial for optimal outcomes.