Contralateral Approach to Bilateral Middle Cerebral Artery Aneurysms: Comparative Study, Angiographic Analysis, and Surgical Results

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Abstract

BACKGROUND:

Bilateral aneurysms located between the 2 middle cerebral artery (MCA) bifurcations may be approachable through a single unilateral approach.

OBJECTIVE:

To identify anatomic parameters based on imaging that would favor a contralateral approach.

METHODS:

From January 1998 to December 2013, we retrospectively identified 173 patients with bilateral intracranial aneurysms. Fifty-one patients had bilateral MCA aneurysms. A total of 38 patients underwent a single craniotomy with a contralateral microsurgical approach (group 1 or contralateral group) and 13 patients underwent bilateral craniotomies (group 2 or bilateral group). For both groups, we analyzed aneurysm characteristics, morphology, size, projections, and distance to the contralateral corridor, as well as surgical time, outcome, and postoperative complications.

RESULTS:

All aneurysms approached contralaterally were unruptured and without wall calcifications. Of the contralaterally approached aneurysms, 97% were smaller than 14 mm. The median length of the contralateral A1 was 13.2 mm (range: 6-19.8 mm) and the median length of the contralateral M1 was 14.2 mm (range: 4.6-21 mm). The contralateral group had a good postoperative outcome (modified Rankin Scale 0-3) in 80% of ruptured cases and 86% of unruptured cases. The median surgical time was 120 minutes (range: 75-255 minutes), 43% shorter than the bilateral group.

CONCLUSION:

The contralateral approach for bilateral MCA aneurysms in selected patients is feasible in experienced hands, with acceptable morbidity and mortality. The contralateral approach requires a meticulous preoperative analysis of the characteristics of the aneurysms to be clipped and of the anatomic constraints of the microsurgical operative corridor.

ABBREVIATIONS:

A1, anterior cerebral artery proximal segment

ABBREVIATIONS:

bMCA, bilateral middle cerebral artery

ABBREVIATIONS:

CTA, computed tomographic angiography

ABBREVIATIONS:

HH, Hunt-Hess scale

ABBREVIATIONS:

IA, intracranial aneurysms

ABBREVIATIONS:

ICA, internal carotid artery

ABBREVIATIONS:

ICAbif, internal carotid artery bifurcation

ABBREVIATIONS:

MCA, middle cerebral artery

ABBREVIATIONS:

M1, middle cerebral artery proximal segment

ABBREVIATIONS:

mRS, modified Rankin Scale

ABBREVIATIONS:

SAH, subarachnoid hemorrhage

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