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Anterior cerebral artery bypass for complex aneurysms: an experience with intracranial-intracranial reconstruction and review of bypass options.

AbstractOBJECT:
The authors describe their experience with intracranial-to-intracranial (IC-IC) bypasses for complex anterior cerebral artery (ACA) aneurysms with giant size, dolichoectatic morphology, or intraluminal thrombus; they determine how others have addressed the limitations of ACA bypass; and they discuss clinical indications and microsurgical technique.
METHODS:
A consecutive, single-surgeon experience with ACA aneurysms and bypasses over a 16-year period was retrospectively reviewed. Bypasses for ACA aneurysms reported in the literature were also reviewed.
RESULTS:
Ten patients had aneurysms that were treated with ACA bypass as part of their surgical intervention. Four patients presented with subarachnoid hemorrhage and 3 patients with mass effect symptoms from giant aneurysms; 1 patient with bacterial endocarditis had a mycotic aneurysm, and 1 patient's meningioma resection was complicated by an iatrogenic pseudoaneurysm. One patient had his aneurysm discovered incidentally. There were 2 precommunicating aneurysms (A1 segment of the ACA), 5 communicating aneurysms (ACoA), and 3 postcommunicating (A2-A3 segments of the ACA). In situ bypasses were used in 4 patients (A3-A3 bypass), interposition bypasses in 4 patients, reimplantation in 1 patient (pericallosal artery-to-callosomarginal artery), and reanastomosis in 1 patient (pericallosal artery). Complete aneurysm obliteration was demonstrated in 8 patients, and bypass patency was demonstrated in 8 patients. One bypass thrombosed, but 4 years later. There were no operative deaths, and permanent neurological morbidity was observed in 2 patients. At last follow-up, 8 patients (80%) were improved or unchanged. In a review of the 29 relevant reports, the A3-A3 in situ bypass was used most commonly, extracranial (EC)-IC interpositional bypasses were the second most common, and reanastomosis and reimplantation were used the least.
CONCLUSIONS:
Anterior cerebral artery aneurysms requiring bypass are rare and can be revascularized in a variety of ways. Anterior cerebral artery aneurysms, more than any other aneurysms, require a thorough survey of patient-specific anatomy and microsurgical options before deciding on an individualized management strategy. The authors' experience demonstrates a preference for IC-IC reconstruction, but EC-IC bypasses are reported frequently in the literature. The authors conclude that ACA bypass with indirect aneurysm occlusion is a good alternative to direct clip reconstruction for complex ACA aneurysms.
AuthorsAdib A Abla, Michael T Lawton
JournalJournal of neurosurgery (J Neurosurg) Vol. 120 Issue 6 Pg. 1364-77 (Jun 2014) ISSN: 1933-0693 [Electronic] United States
PMID24745711 (Publication Type: Journal Article, Review)
Topics
  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Algorithms
  • Anterior Cerebral Artery (diagnostic imaging, surgery)
  • Cerebral Angiography
  • Cerebral Revascularization (methods)
  • Endovascular Procedures (methods)
  • Female
  • Humans
  • Intracranial Aneurysm (diagnostic imaging, surgery)
  • Male
  • Microsurgery (methods)
  • Middle Aged
  • Neurosurgical Procedures (methods)
  • Retrospective Studies
  • Treatment Outcome
  • Young Adult

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