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Complex middle cerebral artery (MCA) aneurysms incorporating parent or branching vessels are often not amenable to standard microsurgical clipping or endovascular embolization treatments. We aim to discuss the treatment of such aneurysms via a combination of surgical revascularization and aneurysm exclusion based on our institutional experience. Thirty-four patients with complex MCA aneurysms were treated with bypass and aneurysm occlusion, 5 with surgical clipping or wrapping only, and 1 with aneurysm excision and primary reanastomosis. Bypasses included superficial temporal artery (STA)-MCA, double-barrel STA-MCA, occipital artery-MCA, and external carotid artery-MCA. After bypass, aneurysms were treated by surgical clipping, Hunterian ligation, trapping, or coil embolization. The average age at diagnosis was 46 years. Of the aneurysms, 67% were large and most involved the MCA bifurcation. Most bypasses performed were STA-MCA bypasses, 12 of which were double-barrel. There were 2 wound-healing complications. All but 2 of the aneurysms treated showed complete occlusion at the last follow-up. There were 3 hemorrhagic complications, 3 graft thromboses, and 4 ischemic insults. The mean follow-up was 73 months. Of patients, 83% reported stable or improved symptoms from presentation and 73% reported a functional status (Glasgow Outcome Scale score 4 or 5) at the latest available follow-up. Cerebral revascularization by bypass followed by aneurysm or parent artery occlusion is an effective treatment option for complex MCA aneurysms that cannot be safely treated by standard microsurgical or endovascular techniques. Double-barrel bypass consisting of 2 STA branches to 2 MCA branches yields adequate flow replacement in most cases. [ABSTRACT FROM AUTHOR]

Neck clipping of the aneurysms arising from the middle cerebral artery (MCA) proximal to the limen insulae is often difficult because of difficulties in securing a bright and wide operative field to observe the aneurysms and surrounding structures, such as the anterior perforated substance, lenticulostriate arteries, and early frontal branch. Our objective was to determine the usefulness of the orbitocranial approach in neck clipping of the aneurysms arising from the MCA proximal to the limen insulae. This prospective study included 7 patients who underwent neck clipping of aneurysms arising from the MCA proximal to the limen insulae through the orbitocranial approach. In addition to conventional pterional craniotomy, the superiolateral orbital rim was resected with a 1-piece fashion. Its procedures, complications, and outcomes were reviewed. Removal of the superolateral orbital rim facilitated a bright and wide observation from the skull base side. It was much easier to identify the anterior perforated substance, lenticulostriate arteries, and early frontal branch around the aneurysm through the orbitocranial approach than through the conventional pterional approach. Neck clipping could be performed completely and safely in all cases. The orbitocranial approach to aneurysms arising from the MCA proximal to the limen insulae provides us a bright and wide operative field compared with the conventional pterional approach, which is useful to secure complete and safe neck clipping by avoiding cerebral contusion and unexpected obstruction of the early frontal branch. [ABSTRACT FROM AUTHOR]

Middle cerebral artery aneurysms (MCAAs) have been considered good candidates for microsurgery. Our objective was to evaluate the risk of complications and the risk factors for complications with microsurgical treatment of MCAAs to better define the indications for microsurgery. We conducted a retrospective cohort study from 3 tertiary neurosurgical units from January 2013 to May 2020. We evaluated the frequency of complications and searched for the risk factors for complications after microsurgery. Complications were defined as a composite criterion with the presence of one of the following: procedural-related death, symptomatic cerebral ischemia, impossible exclusion, incomplete exclusion, or rebleeding of the treated aneurysm and symptomatic surgical site hematoma. A total of 292 MCAAs were treated, with 29 complications (9.9%), including symptomatic cerebral ischemia (4.8%), aneurysm rebleeding (0.3%), surgical site hematoma (1.0%), impossible exclusion (0.3%), and incomplete exclusion (4.1%). Severe complications, defined as death or a modified Rankin scale score of ≥4 at 3 months, were infrequent, occurring in 7 of the 292 patients (2.4%). On multivariate analysis, the risk factors were a ruptured aneurysm, a larger maximum aneurysm size, a larger neck size, and arterial branches passing <1 mm from the aneurysm neck or dome. Microsurgical management of MCAAs can be performed with very low morbidity rates. In some cases, at least for factors that do not result in significant difficulty for endovascular therapy, such as the presence of an en passage artery or ruptured aneurysm, endovascular therapy can be considered to be as safe and effective as clipping. [ABSTRACT FROM AUTHOR]

We report a rare case of unruptured middle cerebral artery aneurysm associated with moyamoya disease. A 48-year-old woman with an 8-year history of moyamoya disease developed a de novo aneurysm at the bifurcation of the right middle cerebral artery. The aneurysm showed rapid enlargement in size in 1 year and surgical treatment was performed. Preoperative images could not clearly define the anatomical relationship between the aneurysm and the surrounding vessels. Intraoperative findings indicated that segmental occlusion of normal arteries that was not visualized made it difficult to define the vascular anatomy. In addition, those occlusions accompanied by improved M1 flow after administration of cilostazol was speculated to have increased hemodynamic stress, leading to the relatively rapid progress of the aneurysm. Understanding the complexity of such process may be valuable in proper decision-making in the management of moyamoya disease patients. [ABSTRACT FROM AUTHOR]

To study clinical significance of augmentation of intraoperative motor evoked potentials (MEPs) during direct open surgery for middle cerebral artery (MCA) aneurysms. Between 2009 and 2017, 134 MCA aneurysm surgeries were performed with intraoperative MEP monitoring. The frequency and cause of augmentation with >50% increase of MEP amplitude from baseline were studied. Factors associated with MEP augmentation were investigated. MEP augmentation was demonstrated in 9 patients. All 9 events were observed just after application of the temporary clip to the parent artery. The ratio of the maximum amplitude to baseline was 2.6 ± 1.1 at an mean of 2.4 ± 1.1 minutes after parent artery occlusion. Ten patients who did not show MEP augmentation after parent artery occlusion were compared with the patients showing MEP augmentation. The distance of the temporary clip point from the midline was smaller in patients with MEP augmentation compared with patients without MEP augmentation (P = 0.033). MEP augmentation was thought to be an early ischemic sign preceding a significant decrease in MEPs during MCA aneurysm surgery. Transient augmentation of MEPs was more frequently observed in cases with a temporary clip applied to the more proximal part of the MCA. [ABSTRACT FROM AUTHOR]

Objective Keyhole craniotomy is a minimally invasive approach for the treatment of middle cerebral artery (MCA) aneurysms. The aim of this study was to compare the clinical outcome between supraorbital keyhole approach and pterional keyhole approach (PKA) in Chinese patients with MCA aneurysm. Methods Consecutive patients with MCA aneurysms were reviewed between January 2013 and December 2017. Efficacy and safety between PKA and supraorbital keyhole approach were compared. Poor outcome was defined as modified Rankin Scale score of 3–6 at discharge. Results This study enrolled 260 patients; 222 (85.4%) had ruptured aneurysm, and 183 (70.4%) received PKA. The distribution of PKA in unruptured and ruptured aneurysms showed no significant difference (P > 0.05). In subgroup analyses, PKA was more likely associated with poor outcome at discharge in patients with unruptured aneurysms (odds ratio = 5.500, 95% confidence interval = 1.013–29.850, P = 0.048), whereas approach selection was not an independent factor predicting poor outcome in patients with ruptured aneurysms (P > 0.05). Conclusions In a Chinese population, supraorbital keyhole approach was superior to PKA in improving outcome in patients with unruptured MCA aneurysms, but the 2 approaches showed comparable outcomes at discharge in patients with ruptured aneurysms. Highlights • In Chinese patients with MCA aneurysm, most surgeons chose PKA rather than SKA. • There was no bias in approach selection between unruptured and ruptured aneurysms. • PKA was associated with poor outcome at discharge for unruptured aneurysms. • Approach selection was not a prognostic factor for ruptured aneurysms. [ABSTRACT FROM AUTHOR]

To assess the safety and efficacy of endovascular treatment (EVT) of unruptured middle cerebral artery (MCA) aneurysms in a retrospective cohort in a high-volume center. Predictors of complications and recurrence were determined. Retrospectively reviewed our database of prospectively collected information for all patients with unruptured MCA aneurysms that were treated by endovascular approach from March 2008 to December 2020. A multivariate analysis was conducted to identify predictors of complications and recurrence. Three hundred and fifty-one patients with 370 unruptured MCA aneurysms underwent EVT were included in this study. Seventy-three aneurysms (19.7%) were treated by coiling without stent, 297 (80.3%) with stent-assisted coiling. The procedures were performed with a technical success rate of 100%. Procedure-related neurological complications occurred in 15 patients (4.1%), including 1 patient died from post-procedural stent thrombosis. Age ≥ 65 years (P = 0.039; OR = 3.400; 95% CI, 1.065–10.860) and aneurysm size ≥ 5 mm (P = 0.009; OR = 15.524; 95% CI, 1.988–121.228) were significantly associated with ischemic complications of EVT. Three hundred and six aneurysms were (87.2%) completed image follow-up (235 DSA and 71 CE-MRA). The median angiographic follow-up time were 7.0 ± 4.3 months (range from 1 to 88 months). Follow-up angiograms showed that 249 aneurysms (81.4%) were completed occluded, 29 aneurysms (9.5%) were improved, 17 aneurysms (5.6%) were stable, and 11 aneurysms (3.6%) were recanalized and 10 of them accepted retreatments. Aneurysm size ≥ 10 mm was a predictor of recanalization (P = 0.004; OR = 11.213; 95% CI, 2.127–59.098) and stent-assisted coiling can significantly reduce recanalization (P = 0.004; OR = 0.105; 95% CI, 0.023–0.479). EVT is a safe and effective therapeutics for unruptured MCA aneurysms management, and provides durable aneurysm occlusion rate during follow-up. Large MCA aneurysms have higher recurrence and ischemic complications risk after EVT. Stent-assisted coiling can significantly reduce the recurrence rate without increasing the risk of complications. [ABSTRACT FROM AUTHOR]

Background Preservation of the superficial Sylvian veins (SSVs) is essential to prevent neurologic deficits during Sylvian dissection. We describe an appropriate surgical approach for unruptured middle cerebral artery (MCA) aneurysms to preserve these veins by using indocyanine green videoangiography (ICG-VA). Methods Between August 2014 and August 2015, we performed microsurgical clipping for 37 unruptured MCA aneurysms in 36 patients. We classified all of the cases into 3 types according to the location between the Sylvian fissure and the SSV. We defined 3 surgical approaches (frontosylvian, intersylvian, and temporo-sylvian) based on the SSV and investigated the proper surgical approach according to the type of case. Results In our study, most SSVs were located above the Sylvian fissure (fissure type, 64.9%). The SSV was located on the temporal lobe in 10 cases (temporal type) and on the frontal lobe in 3 cases (frontal type). The frontosylvian approach (splitting between the SSV and frontal lobe) was performed in all of the patients with temporal type; the temporo-sylvian approach (splitting between the SSV and temporal lobe) was performed in all of the patients with frontal type and single SSV of fissure type. The intersylvian approach (splitting between the frontal and temporal SSV, or among multiple SSVs) was successfully performed in the patients with double or multiple SSVs of fissure type. No venous complications occurred that were related to the surgical approach. Conclusions Correct dissection strategy using intraoperative ICG-VA is greatly useful to define the optimal surgical approach without vein injury. [ABSTRACT FROM AUTHOR]

Objective: Aggressive surgery seems mandatory for poor-grade middle cerebral artery (MCA) aneurysm with associated intracerebral hemorrhage (ICH). However, primary decompressive craniectomy (DC) is controversial. We performed a case control study to define the role of primary DC. Materials and methods: We analyzed data from the two cohorts: a multicenter prospective poor-grade aSAH registry study (AMPAS); and the National Clinical Research Center for Neurological Diseases (NCRCND) database of poor-grade patients. Outcome was assessed by modified Rankin Scale (mRS) and was dichotomized into favorable (mRS 0-3) and unfavorable outcome (mRS 4-6). We compared major complication rates, mortality and outcomes between primary DC and control groups. Results: Twenty-four patients with primary DC were included in the study group. Fourteen patients without DC were included in the control group. Patients with younger age and lower Glasgow coma score (GCS) more often underwent primary DC. Major complications did not differ between the two groups. Fourteen (58%) patients had a favorable outcome, and the mortality was 29%. Primary DC appeared to have lower in-hospital mortality and have better outcome. Adjusting for age and admission GCS, primary DC was not significantly associated with decreased mortality and improved outcomes. Conclusions: Although primary DC does not increase postoperative complication and mortality risk, current results showed primary DC does not seem to be significantly associated with improved outcomes. However, more than one half of patients most benefit from primary DC. Further prospective controlled studies are warranted to clarify the issue. [ABSTRACT FROM AUTHOR]

Abstract: Several stent-supported coiling techniques have been devised for treating wide-necked bifurcation aneurysms including the Y-stent and waffle-cone constructs. The Y-stent technique is not technically possible with obtusely oriented daughter vessels, and the waffle-cone method is inadequate for aneurysms with necks exceeding the stent’s maximal expansion diameter. We describe here the novel use of the Solitaire electrolytically detachable slotted stent (Solitaire, ev3, Irvine, CA, USA) featuring large-sized cells to fashion a concentric “double waffle-cone” construct. This method enabled the doubling of the neck coverage to treat an ultra-wide necked middle cerebral aneurysm with obtusely oriented daughter branches. The technique relies on the intra-cell crossing of the first stent using the second stent delivery microcatheter and fine tuning the relative position with the aid of cross-sectional cone-beam computed tomographic angiography to achieve optimal coverage of the neck prior to detachment of the stents in position. A retrievable stent with large cells such as the Solitaire device is optimal for this application given the need for relative adjustment of the deployment before final stent release to avoid under- or over-penetration of the distal stent struts into the aneurysm dome. An additional advantage of this approach over the kissing-stent technique is the absence of intraluminal stent struts, which was confirmed here by down-the-barrel cross-sectional imaging. The double waffle-cone construct enabled the successful coiling of the aneurysm with no post-procedural ischemic events detected on diffusion-weighted MRI and with stable complete embolization and no residual filling or in-stent stenosis at 6month follow-up. [Copyright &y& Elsevier]

Objective: Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. We hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures. Methods: A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma with or without subarachnoid hemorrhage. The mean age of our patients was 52.5 years (range, 10–82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time as their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (e.g., age, sex, admission HH grade) and patients' final outcome. Results: The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital after surgery, whereas 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale 4-5 at discharge, whereas 15% (12 of 78) displayed Glasgow outcome scale 4-5 at 6-month follow-up. Age and sex did not affect outcome. Conclusions: Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm. Long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures. [Copyright &y& Elsevier]

Abstract: In experiments turbulence has previously been shown to occur in intracranial aneurysms. The effects of turbulence induced oscillatory wall stresses could be of great importance in understanding aneurysm rupture. To investigate the effects of turbulence on blood flow in an intracranial aneurysm, we performed a high resolution computational fluid dynamics (CFD) simulation in a patient specific middle cerebral artery (MCA) aneurysm using a realistic, pulsatile inflow velocity. The flow showed transition to turbulence just after peak systole, before relaminarization occurred during diastole. The turbulent structures greatly affected both the frequency of change of wall shear stress (WSS) direction and WSS magnitude, which reached a maximum value of 41.5Pa. The recorded frequencies were predominantly in the range of 1–500Hz. The current study confirms, through properly resolved CFD simulations that turbulence can occur in intracranial aneurysms. [Copyright &y& Elsevier]

Abstract: Objectives: To describe surgical strategies using cerebral revascularization for complex middle cerebral artery aneurysms unsuitable to microsurgical clipping. Materials and methods: In this study, the clinical features, case management, and results in 9 consecutive patients who underwent 10 cerebral revascularization procedures between January 1999 and April 2008 were retrospectively analyzed. The patient population consisted of 6 men and 3 women whose ages ranged from 15 to 71 years (mean, 42.4 years). The size of the aneurysms ranged from 12 to 35mm (mean, 24.3mm). Treated aneurysms were located in the M1 segment in 2 patients, the middle cerebral artery (MCA) bifurcation in 3 patients, the distal M3 segment in 3 patients, and the anterior temporal artery (ATA; the early cortical branch of the M1 segment) in 1 patient. A total of 10 revascularizations were performed. Three aneurysms were saccular and six aneurysms were fusiform. For the fusiform aneurysms of the M1 segment in 2 patients, superficial temporal artery (STA) trunk–saphenous vein (SV)–MCA bypasses followed by trapping were performed. For the large saccular MCA bifurcation aneurysms in 3 patients, STA–MCA bypasses followed by complete neck clipping, including the revascularized branch with the preservation of the flow of the other branch, were performed in 2 cases, and a STA trunk–SV–MCA bypass secondary to direct neck clipping with the preservation of both M2 branches was performed in 1 case. For the fusiform distal MCA aneurysms, STA–MCA bypasses in 2 patients and in situ MCA–MCA bypasses in 2 patients were performed. In one case involving distal MCA fusiform aneurysm, STA–MCA bypass and MCA–MCA bypass were performed simultaneously. In a case involving fusiform ATA aneurysm, primary reanastomosis after aneurysm excision was performed in 1 patient. Results: The post-operative 3-month Glasgow outcome scales were good recovery in 6 patients, severe disability in 1 patient, a vegetative state in 1 patient, and death in 1 patient. A follow-up angiography was performed in 6 patients and revealed a patent bypass in 5 patients. In one case treated by direct neck clipping secondary to cerebral revascularization, the angiography obtained 2 weeks later showed graft occlusion, but there were no neurologic symptoms. Among the unfavorable outcomes of 3 patients who did not undergo follow-up angiography, surgery-related morbidity secondary to cerebral infarction was due to the size discrepancy between the donor and recipient vessels in 1 patient with severe disability. In the other 2 patients, the preoperative conditions were Hunt and Hess grade V. Conclusions: Cerebral revascularization is a safe and effective technique of treatment for selective cases of complex large or giant aneurysms and unclippable fusiform aneurysms in the MCA. [Copyright &y& Elsevier]

Abstract: Surgical clipping is preferred to endovascular coil embolization for the treatment of middle cerebral artery (MCA) aneurysms. The aim of this study was to describe our experience of coiling for MCA aneurysms, to analyze the reasons for choosing coiling instead of clipping, and to evaluate the appropriateness of the choice. We retrospectively reviewed data of 30 patients who had coiling for MCA aneurysms in our Institute from January 2008 to February 2011. We analyzed the morphologies, techniques, angiographic results and complications of 30 aneurysms treated with coiling, and compared the outcomes with those of 78 clipped aneurysms during the same period. The most common reason for choosing coiling instead of clipping was the short length of the M1 artery (17/30, 56.7%). Complete obliteration of the aneurysm was achieved in 28 of 30 coiling patients (93%) and in 72 of 78 clipping patients (92%). In the coiling group, two of 30 patients (6.7%) had post-procedural infarctions on radiologic evaluation, with only one infarction in clinically relevant territory. There was one intra-procedural rupture and one aneurysm recanalization requiring retreatment in the coiling group. In the clipping group, two infarctions, one subdural hygroma and two intracerebral hematomas were found as postoperative complications, with two clinical deteriorations. Endovascular coil embolization should be considered for treatment of MCA aneurysms as it has angiographic results equivalent to surgical clipping and acceptable post-procedural complications. It is particularly appropriate for patients with serious medical problems or where there is the risk of damaging perforating lenticulostriate arteries on the MCA during surgery. [Copyright &y& Elsevier]

Treatment of complex middle cerebral artery (MCA) aneurysms are challenging; however, an appropriate surgical strategy can ensure favorable outcomes. Notably, a protective bypass strategy is essential to treat complex aneurysms and involves the creation of a bypass channel distal to the aneurysm before repairing it. A protective bypass enables the surgeon to establish adequate distal blood flow during the approach to the aneurysm, as well as during additional revascularization. This Video 1 describes complex bypass surgery that successfully treated multiple fusiform aneurysms, including a thrombosed giant aneurysm of the MCA. A 12-year-old girl presented with a history of chronic headache and incidentally diagnosed multiple fusiform aneurysms along the course of the right internal carotid artery to the MCA, including a thrombosed giant aneurysm of the M2 segment of the MCA (M2) superior trunk. The aneurysms were treated by trapping and excision along with a superficial temporal artery to MCA triple bypass, and an M2-radial artery graft-M2 bypass. The patient developed mild left hemiparesis postoperatively but recovered well and was discharged with a modified Rankin Scale score of 0. The pathophysiology of this patient should be different from common saccular aneurysm because of young age and multiple fusiform shape. Hence continuous follow-up is essential. The next surgical strategy should be reconsidered according to the situation if the recurrence is occurred. This surgical video shows the surgical strategy and stepwise procedure to treat complex aneurysms and will be useful to vascular neurosurgeons to devise a surgical approach utilizing a "protective bypass strategy." [ABSTRACT FROM AUTHOR]

Microsurgical or endovascular treatment for blood-blister aneurysm remains a technical challenge. This video demonstrates a microsurgical suturing technique for ruptured blood-blister aneurysm of the left middle cerebral artery. The patients experienced favorable clinical outcomes without apparent stenosis of the normal vessel wall. Highlights • Surgical or endovascular treatment method for blood-blister aneurysm (BBA) remains a technical challenge. • This video demonstrated a BBA of the middle cerebral artery that was managed by a microsurgical suturing technique. • Complete obliteration of the aneurysm without parent vessel occlusion was observed postoperatively. • The microsurgical suturing technique is a safe and effective method for the management of BBA. [ABSTRACT FROM AUTHOR]

This video case illustrates key surgical steps required in safe management of a giant recurrent previously coiled middle cerebral artery (MCA) aneurysm (Video 1). The patient described in this case was a 68-year-old man who presented with sudden-onset severe headache and dizziness. The patient had a history of a prior coil embolization of a 12-mm left middle cerebral artery aneurysm at an outside hospital. Imaging demonstrated recurrence now of a giant left middle cerebral artery aneurysm with coil compaction and left temporal lobe edema. Magnetic resonance imaging further demonstrated thrombus in the aneurysm and aneurysm wall enhancement concerning for impending rupture. Given the aneurysm size, imaging features, and mass effect, the aneurysm was treated with microsurgical clipping. This case is valuable to the literature with a clear video case illustration of aneurysm dome excision, aneurysm endarterectomy, and picket fence aneurysm neck reconstruction. Aneurysm dome excision is critical for treatment of giant aneurysms causing mass effect and was only used in this case because thrombus and coil mass did not allow for direct clipping across the neck without compromise of the MCA M2 branch. Hence, this video highlights key technical tenets, such as safe thrombus removal and adequate cleaning of the endoluminal surface and preparedness for bypass in challenging cases. [ABSTRACT FROM AUTHOR]

Mycotic aneurysm, also referred to as infected aneurysm, is a rare entity that may result from the bacterial infection or infective endocarditis. 1-3 The treatment options include conservative medication and endovascular or direct microsurgical intervention. 1,4,5 However, the optimal strategy remains unknown and cerebral revascularization may be required in some rare cases. 6 In this surgical video, we demonstrate a distal middle cerebral artery (MCA) mycotic aneurysm that we treated by intracranial-intracranial bypass with an interpositional graft. Our patient is a 53-year-old male who presented with a 6-day history of severe headache. He was subsequently admitted to our institution. Preoperative computed tomography angiography showed a left temporal hematoma (>30 mL) and an opercular segment of the MCA (M3) aneurysm, which was highly suspicious for mycotic origin. A standard frontotemporal craniotomy was carried out with preservation of superficial temporal artery (STA). Following the sylvian fissure dissection, the aneurysm was exposed with the characteristics of a thick wall and an undefinable neck, which made direct clip application difficult. The aneurysm was resected initially, and 2 cut ends were reconnected by an STA graft. Following arterial reconstruction, intraoperative Doppler revealed a patent status of the interpositional graft vessel. Postoperatively, no neurologic deficit was observed and computed tomography angiography demonstrated total elimination of the aneurysm without stenosis of the graft vessel. Low-molecular dextran was prescribed rather than aspirin, as there was concern for hemorrhage. Antibiotic treatment was used for at least 4 weeks, and the patient was transferred to the inpatient cardiology team for management of endocarditis. A 4-month follow-up angiogram showed a patent STA and excellent left distal MCA blood flow (Video 1). The favorable outcome of this case revealed that MCA-to-MCA bypass with interpositional graft is a safe, effective method for the unclippable cerebral aneurysm. As other authors have asserted, a full dose of long-term antibiotic therapy remains essential following intervention. 7 Meanwhile, dextran has proved to be a viable alternative for anticoagulation during perioperative management of bypass surgery. 8,9 [ABSTRACT FROM AUTHOR]

Background Regardless of acceptable surgical results of middle cerebral artery aneurysms (MCAs), MCA territory infarction (MCATI) remains a major obstacle to achieving a good outcome. We investigated the MCATI in patients with surgically treated MCA aneurysms. Methods The data of 286 consecutive patients with 322 MCA aneurysms were evaluated retrospectively. The aneurysm location was classified as early frontal cortical branch (EFCB), early temporal cortical branch (ETCB), bifurcation or trifurcation (M1-2), and distal aneurysms on the insular, opercular, or cortical segments of the MCA (distal MCA). Neurologic worsening was defined as an increase in 1 or more modified Rankin Scale (mRS) scores. Results Multivariate analysis identified EFCB location as the sole risk factor for MCATI (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.2–12; P = 0.021) and MCATI (OR, 18; 95% CI, 2.8–117; P = 0.002) and a larger size ratio (OR, 1.4; 95% CI, 1.1–1.8; P = 0.019) were related to 12-month neurologic worsening ( n = 6; 1.9%). During follow-up (median, 885 days; interquartile range, 485–1229 days), posttreatment rupture and aneurysm recurrence were not observed. Conclusions In the present study, compared with M1-2 aneurysms, MCATIs were observed more frequently in EFCB aneurysms, and the presence of MCATI and a larger size ratio were related to 12-month neurologic worsening in patients with surgically treated MCA aneurysms. [ABSTRACT FROM AUTHOR]

Background Herpes simplex encephalitis (HSE) after neurosurgical procedures is extremely uncommon, and the few published case reports mainly described herpes simplex virus type 1 (HSV-1) as being culpable. We present a rare case of HSV-2 encephalitis after craniotomy and describe its pathophysiology and optimal management. Case Description A 70-year-old woman underwent an elective resection of a recurrent left sphenoid wing meningioma and clipping of a left middle cerebral artery aneurysm, the latter having been found incidentally. She returned to our department with clinical findings suggestive of meningitis 12 days after the operation. Her lack of response to empiric antibiotic treatment, taken together with the lymphocyte-predominant initial cerebrospinal fluid obtained by lumbar puncture and the electroencephalographic indications of encephalopathy, led to the suspicion of a diagnosis of HSE, which was later confirmed by a polymerase chain reaction test positive for HSV-2. The patient was then successfully treated with intravenous acyclovir for 2 weeks followed by another week of oral acyclovir treatment before being discharged. Conclusions The present case stresses the importance of recognizing the relatively rare entity of HSE after craniotomy. Timely correct diagnosis will expedite the initiation of appropriate treatment. [ABSTRACT FROM AUTHOR]