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Combined Surgical Clipping, Endovascular Coiling, and Saphenous Vein Bypass graft for treatment of a Giant Serpentine Aneurysm of the Middle Cerebral Artery

Case Presentation by
Hana Choe: University of Buffalo Visiting Medical Student

Introduction

Surgical clipping is the definitive treatment for many intracranial aneurysms, giant serpentine aneurysms measuring greater than 2.5cm pose unique difficulties for surgical management. Giant serpentine aneurysms lack a definable neck and often involve the parent vessels, making occlusion difficult. Giant aneurysms are frequently partially thrombosed. Angiography alone may be insufficient to define the extent of aneurysmal growth. Three dimensional angiography and CT Angiograms are helpful in defining the anatomical constraints in neurovascular surgical management.

Presentation

A 57-year-old male presented to the Mount Sinai Department of Neurosurgery after radiological evaluation revealed a giant aneurysm of the middle cerebral artery. Figures 1 and 2 demonstrate the CT and MRI characteristics. Figures 3A and B show the angiogram and three-dimensional reconstuction.

Surgical Procedure

The patient underwent a Saphenous Vein Bypass graft from the External Carotid Artery to the Middle cerebral artery by Joshua Bederson, M.D. Figure 4 shows the intraoperative exposure. The next day, he underwent endovascular coiling of the aneurysm and proximal middle cerebral artery by Aman Patel, M.D. Figures 5A and B show the postoperative appearance.

Postoperative Course

The patient tolerated the procedure well and was discharged to on the fifth postoperative day. and has returned to his baseline activities.

Discussion

Giant serpentine aneurysms represent a small portion of intracranial aneurysms with a reported incidence of 3 percent to 5 percent. They may present with hemorrhage or symptoms of mass effect, including seizures, visual disturbance, chronic headache. Serpentine aneurysms commonly arise along the MCA. The selection of treatment modality will be dictated by the anatomy of the aneurysm and the patient's cerebral vasculature, e.g. the lack of an anterior communicating artery.

Conclusion

Patients with giant serpentine aneurysms can be managed successfully with an EC-IC bypass graft followed by endovascular coil thrombosis of the aneurysm.

References

• Anson, Lawton, and Spetzler. 1996. Characteristics and surgical treatment of dolichoectatic and fusiform aneurysm. J Neurosurg 84: 185-193.
• Greene, Anson, and Spetzler. 1993. Giant serpentine middle cerbral artery aneurysm treated by extracranial-intracranial bypass. J Neurosurg 78: 974-978.
• Horowitz, Yonas, Jungreis, and Hung. 1994. Management of a giant middle cerebral artery fusiform serpentine aneurysm with distal clip application and retrograde thrombosis: Case report and review of the literature. Surg Neurol 41: 221-5.
• Neurovascular Surgery, Eds Carter and Spetzler. McGraw-Hill, Inc: New York, 1995.
• Patel, Sherman, Hemmati, and Ferguson. 1981. Giant serpentine intracranial aneurysms. Surg Neurol 16:402-7.