The application of intracranial-intracranial bypass for the treatment of complex intracranial aneurysms

doi:10.3969/j.issn.1672-6731.2024.08.008

Chinese Journal of Contemporary Neurology and Neurosurgery ›› 2024, Vol. 24 ›› Issue (8): 644-650. doi: 10.3969/j.issn.1672-6731.2024.08.008

• Intracranial-Intracranial Bypass for Complex Intracranial Aneurysms • Previous Articles Next Articles

The application of intracranial-intracranial bypass for the treatment of complex intracranial aneurysms

Ying SU¹, Pei-xi LIU²^,*(), Yuan SHI², Pei-liang LI², Qing-zhu AN², Yan-long TIAN², Wei ZHU²^,*()

1. Department of Neurosurgery, Linyi Central Hospital, Linyi 276400, Shandong, China
2. Department of Neurosurgery, National Center for Neurological Disorders; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration; Neurosurgical Institute of Fudan University; Shanghai Clinical Medical Center of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200032, China

Received:2024-03-19 Online:2024-08-25 Published:2024-08-29
Contact: Pei-xi LIU, Wei ZHU
Supported by:
Shanghai Outstanding Academic Leaders Program(21XD1400600); Shanghai "Rising Stars Medical Talent" Young Medical Talents Training Funding Program(30302106001)

复杂颅内动脉瘤颅内-颅内血管搭桥术

苏赢¹, 刘佩玺²^,*(), 史源², 李培良², 安庆祝², 田彦龙², 朱巍²^,*()

1. 276400 山东省临沂市中心医院神经外科
2. 200032 复旦大学附属华山医院神经外科国家神经疾病医学中心上海市脑功能重塑及神经再生重点实验室复旦大学神经外科研究所上海市神经外科临床医学中心

通讯作者: 刘佩玺, 朱巍
作者简介:
苏赢与刘佩玺对本文有同等贡献

SU Ying and LIU Pei-xi contributed equally to the article
基金资助:
上海市优秀学术带头人计划项目(21XD1400600); 上海市“医苑新星”青年医学人才培养资助计划项目(30302106001)

Abstract

Abstract:

Objective: To explore the efficacy and safety of intracranial-intracranial bypass for the treatment of complex intracranial aneurysms. Methods and Results: A total of 32 patients with complex intracranial aneurysms who were hospitalized for treatment at Huashan Hospital, Fudan University from January 2015 to December 2023 were included. Surgical methods included in-situ bypass, reimplantation, reanastomosis and bypass with interposition graft. For middle cerebral artery (MCA) aneurysms (n = 16), there were 5 cases of in-situ bypass, one case of reimplantation, 3 cases of reanastomosis, and 7 cases of bypass with interposition graft. For anterior cerebral artery (ACA) aneurysms (n = 8), there were 5 cases of in-situ bypass and 3 cases of reimplantation. For anterior communicating artery (ACoA) aneurysms (n = 2), both cases were in-situ bypass. For posterior circulation aneurysms (n = 6), there were 3 cases of in-situ bypass, 2 cases of reanastomosis, and one case of bypass with interposition graft. The intraoperative graft vessels patency rate was 100%. Among the 23 patients who participated in follow-up imaging for more than 6 months postoperatively, no obvious recurrence was indicated by imaging. Among the 28 patients who participated in modified Rankin Scale (mRS) follow-up, there was one case of 5, 5 cases of 3, 2 cases of 2, one case of 1, and 19 cases of 0. Postoperative hemorrhagic complications occurred in 3 cases (9.37%), and ischemic complications occurred in 10 cases (31.25%), with no patients requiring unplanned secondary surgery for complication treatment. Conclusions: Intracranial-intracranial bypass has good efficacy and safety for the treatment of complex intracranial aneurysms and has unique advantages in the microsurgical treatment of complex intracranial aneurysms.

Key words: Intracranial aneurysm, Cerebral revascularization, Hemodynamics

摘要：

目的: 探讨颅内-颅内血管搭桥术治疗复杂颅内动脉瘤的疗效及安全性。方法与结果: 纳入2015年1月至2023年12月在复旦大学附属华山医院行颅内-颅内血管搭桥术的32例复杂颅内动脉瘤患者，手术方式为脑血管原位重建、再移植、再吻合及短距桥接，其中大脑中动脉动脉瘤（16例）原位重建5例，再移植1例，再吻合3例，短距桥接7例；大脑前动脉动脉瘤（8例）原位重建5例，再移植3例；前交通动脉动脉瘤（2例）均为原位重建；后循环动脉瘤（6例）原位重建3例，再吻合2例，短距桥接1例。术中桥血管通畅率达100%，无桥血管闭塞患者。参与术后6个月以上影像学随访的23例患者影像学均未见明显复发；参与改良Rankin量表随访的28例患者中5分1例，3分5例，2分2例，1分1例，0分19例。术后出现出血性并发症3例（9.37%），缺血性并发症10例（31.25%），无患者接受非计划二次手术治疗并发症。结论: 颅内-颅内血管搭桥术治疗复杂颅内动脉瘤疗效及安全性较好，在复杂颅内动脉瘤的显微外科治疗中具有独特优势。

关键词: 颅内动脉瘤, 脑血管重建术, 血流动力学

Ying SU, Pei-xi LIU, Yuan SHI, Pei-liang LI, Qing-zhu AN, Yan-long TIAN, Wei ZHU. The application of intracranial-intracranial bypass for the treatment of complex intracranial aneurysms[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(8): 644-650.

苏赢, 刘佩玺, 史源, 李培良, 安庆祝, 田彦龙, 朱巍. 复杂颅内动脉瘤颅内-颅内血管搭桥术[J]. 中国现代神经疾病杂志, 2024, 24(8): 644-650.

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Figures/Tables 3

Figure 1 A 17-year-old male patient (Case 16) was admitted (June 2023) due to recurrent headache for 5 years. The clinical diagnosis was dissection aneurysm of the M1 segment of left MCA, and A1 - RA - M2 bypass was performed. Surgical approach and plan: the aneurysm was located at the end of the M1 segment of left MCA and was a dissection aneurysm, making conventional clipping and aneurysmoraphy unfeasible. The RA was chosen as the graft for blood flow reconstruction, and A1 - RA - M2 bridge was conducted. Because the aneurysm had perforating arteries, proximal occlusion was performed, with the perforators receiving blood supply from the distal bypass graft. Preoperative and postoperative imaging and intraoperative findings Preoperative axial CT showed a high - density lesion in the anterior left temporal lobe (arrow indicates, Panel 1a). Preoperative anteroposterior, lateral and oblique DSA showed a dissection aneurysm in the M1 segment of left MCA (arrows indicate, Panel 1b-1d). Preoperative enhanced VW - HRMRI showed significant enhancement of the aneurysm wall with intra sac mix signals showing turbulent blood flow inside the aneurysm (arrow indicates, Panel 1e). Intraoperative end-to-side anastomosis between RA (arrow indicates) and A1 (Panel 1f). End-to-side anastomosis between RA and M2 (arrow indicates, Panel 1g). Proximal occlusion of the aneurysm (Panel 1h). Postoperative axial T₂WI (Panel 1i), fat suppression T₂-FLAIR (Panel 1j) and DWI (Panel 1k) showed no significant edema or ischemia in the surgical area on the 3rd day after operation. Postoperative DSA of the left ICA showed no aneurysm visualization, and the graft was patent on the 4th day after operation (Panel 1l).

Figure 2 A 57 - year - old female patient (Case 23) was admitted (February 2022) due to an aneurysm was found during physical examination becase of experiencing tongue numbness for 4 months. The clinical diagnosis was an aneurysm at the A2-A3 bifurcation of right ACA. A staged approach was planned: performing a bypass first, followed by the implantation of a flow diverter. Surgical strategy and plan: the aneurysm was located at the bifurcation, and the implantation of the flow diverter could alter the blood flow to the other A3, which might cause cerebral infarction in the region supplied by A3. The parent artery had already developed aneurysmal changes, with no normal proximal artery, making conventional craniotomy for clipping and remodeling difficult and prone to recurrence. A3 -A3 side-to-side anastomosis was first performed to establish distal A3 blood supply, followed by the placement of a flow diverter in a second stage to remodel the aneurysmal artery. Preoperative and postoperative imaging and intraoperative findings Preoperative right ICA DSA showed an aneurysm at the A2-A3 bifurcation (arrow indicates, Panel 2a). Preoperative right ICA DSA 3D volume reconstruction showed the aneurysm located at the A2 - A3 bifurcation involving both A3 branches (arrow indicates, Panel 2b). Left ICA DSA showed no bilateral ACA (Panel 2c). The right ICA neck compression test indicated open ACoA (Panel 2d). Preoperative enhanced VW -HRMRI showed significant enhancement of the aneurysm wall (arrow indicates, Panel 2e). Intraoperative exposure of both A3 branches (Panel 2f). The side - to - side anastomosis of both A3 branches (arrow indicates, Panel 2g). Intraoperative ICGA showed patency of both A3 branches (Panel 2h). Postoperative axial CT showed no obvious bleeding on the 1st day after operation (Panel 2i). Postoperative axial DWI showed no significant cerebral infarction on the 3rd day after operation (Panel 2j). In second stage operation, right ICA DSA after flow diverter placement showed significant retention of contrast agent within the aneurysm (Panel 2k). Eight months after operation, right ICA DSA showed disappearance of the aneurysm (Panel 2l).

Table 1. The locations and surgical methods for the treatment of complex intracranial aneurysms with intracranial-intracranial bypass in 32 cases

序号	动脉瘤部位	特殊动脉瘤	动脉瘤处理方式	血流重建方式
1	MCA M2	非囊性动脉瘤	近端阻断	M2-M2侧侧吻合
2	MCA M2	> 10 mm	夹闭	M2-M2端侧吻合
3	MCA M1	> 10 mm	孤立	A1-RA-M3
4	MCA M2	非囊性动脉瘤	切除	M2-M2端端吻合
5	MCA M3	> 10 mm	切除	M3-M3端端吻合
6	MCA M1	非囊性动脉瘤	孤立	A1-RA-M2
7	MCA M1-M2分叉部	非囊性动脉瘤	近端阻断	A1-RA-M2
8	MCA M1-M2分叉部	> 10 mm	孤立	M3-M3侧侧吻合
9	MCA M1-M2分叉部	> 10 mm	近端阻断	A1-RA-M2
10	MCA M2	> 10 mm，非囊性动脉瘤	孤立	A1-RA-M2 + M2-M2侧侧吻合
11	MCA M1-M2分叉部	非囊性动脉瘤	夹闭	M2-M2侧侧吻合
12	MCA M1-M2分叉部	非囊性动脉瘤	塑形夹闭	M2-M2侧侧吻合
13	MCA M1-M2分叉部	> 10 mm，非囊性动脉瘤	切除	“Y”形吻合
14	MCA M1	> 10 mm	近端阻断	A1-RA-M2
15	MCA M2	非囊性动脉瘤	孤立	M3-M3侧侧吻合
16	MCA M1	非囊性动脉瘤	近端阻断	A1-RA-M2
17	ACA A4	> 10 mm，非囊性动脉瘤	切除	A3-A3端侧吻合
18	ACA A3	非囊性动脉瘤	孤立	A3-A3侧侧吻合
19	ACA A2	> 10 mm，非囊性动脉瘤	孤立	A3-A3端侧吻合
20	ACA A2	> 10 mm，非囊性动脉瘤	孤立	A3-A3侧侧吻合
21	ACA A2	> 10 mm	孤立	A3-A3侧侧吻合
22	ACA A2	非囊性动脉瘤	夹闭	A3-A3侧侧吻合
23	ACA A2-A3分叉部	> 10 mm，非囊性动脉瘤	远端阻断	A3-A3侧侧吻合
24	ACA A2	> 10 mm	近端阻断	A3-A3端侧吻合
25	PICA-PCA P2远端	非囊性动脉瘤	切除	PICA-PICA端端吻合
26	PICA起始部	> 10 mm，非囊性动脉瘤	孤立	PICA-PICA侧侧吻合
27	PICA起始部	非囊性动脉瘤	切除	PICA-PICA端端吻合
28	PICA起始部	非囊性动脉瘤	孤立	PICA-PICA侧侧吻合
29	PCA P1	非囊性动脉瘤远端	阻断	A1-RA-P2
30	PICA-PCA P2远端	非囊性动脉瘤	孤立	PICA-PICA侧侧吻合
31	ACoA	> 10 mm	近端阻断	A3-A3侧侧吻合
32	ACoA	> 10 mm	近端阻断	A2-A2侧侧吻合

Table 1. The locations and surgical methods for the treatment of complex intracranial aneurysms with intracranial-intracranial bypass in 32 cases

序号	动脉瘤部位	特殊动脉瘤	动脉瘤处理方式	血流重建方式
1	MCA M2	非囊性动脉瘤	近端阻断	M2-M2侧侧吻合
2	MCA M2	> 10 mm	夹闭	M2-M2端侧吻合
3	MCA M1	> 10 mm	孤立	A1-RA-M3
4	MCA M2	非囊性动脉瘤	切除	M2-M2端端吻合
5	MCA M3	> 10 mm	切除	M3-M3端端吻合
6	MCA M1	非囊性动脉瘤	孤立	A1-RA-M2
7	MCA M1-M2分叉部	非囊性动脉瘤	近端阻断	A1-RA-M2
8	MCA M1-M2分叉部	> 10 mm	孤立	M3-M3侧侧吻合
9	MCA M1-M2分叉部	> 10 mm	近端阻断	A1-RA-M2
10	MCA M2	> 10 mm，非囊性动脉瘤	孤立	A1-RA-M2 + M2-M2侧侧吻合
11	MCA M1-M2分叉部	非囊性动脉瘤	夹闭	M2-M2侧侧吻合
12	MCA M1-M2分叉部	非囊性动脉瘤	塑形夹闭	M2-M2侧侧吻合
13	MCA M1-M2分叉部	> 10 mm，非囊性动脉瘤	切除	“Y”形吻合
14	MCA M1	> 10 mm	近端阻断	A1-RA-M2
15	MCA M2	非囊性动脉瘤	孤立	M3-M3侧侧吻合
16	MCA M1	非囊性动脉瘤	近端阻断	A1-RA-M2
17	ACA A4	> 10 mm，非囊性动脉瘤	切除	A3-A3端侧吻合
18	ACA A3	非囊性动脉瘤	孤立	A3-A3侧侧吻合
19	ACA A2	> 10 mm，非囊性动脉瘤	孤立	A3-A3端侧吻合
20	ACA A2	> 10 mm，非囊性动脉瘤	孤立	A3-A3侧侧吻合
21	ACA A2	> 10 mm	孤立	A3-A3侧侧吻合
22	ACA A2	非囊性动脉瘤	夹闭	A3-A3侧侧吻合
23	ACA A2-A3分叉部	> 10 mm，非囊性动脉瘤	远端阻断	A3-A3侧侧吻合
24	ACA A2	> 10 mm	近端阻断	A3-A3端侧吻合
25	PICA-PCA P2远端	非囊性动脉瘤	切除	PICA-PICA端端吻合
26	PICA起始部	> 10 mm，非囊性动脉瘤	孤立	PICA-PICA侧侧吻合
27	PICA起始部	非囊性动脉瘤	切除	PICA-PICA端端吻合
28	PICA起始部	非囊性动脉瘤	孤立	PICA-PICA侧侧吻合
29	PCA P1	非囊性动脉瘤远端	阻断	A1-RA-P2
30	PICA-PCA P2远端	非囊性动脉瘤	孤立	PICA-PICA侧侧吻合
31	ACoA	> 10 mm	近端阻断	A3-A3侧侧吻合
32	ACoA	> 10 mm	近端阻断	A2-A2侧侧吻合

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