title: Management of giant middle cerebral artery aneurysms with incorporated branches: partial endovascular coiling or combined extracranial-intracranial bypass--a team approach.
abstract: OBJECTIVE
  Our goal was to assess the long-term anatomic and clinical outcomes in patients with giant middle cerebral artery (MCA) aneurysms treated by endovascular coil embolization alone or in combination with cerebral revascularization.
  
  
  METHODS
  One hundred twenty-six patients with giant intracranial aneurysms were endovascularly treated at the University of California, Los Angeles, between 1990 and 2007. Of these, 9 patients had partially thrombosed MCA aneurysms with incorporated branches. Five patients presented with symptoms of mass effect, 3 had seizures, 2 had episodes of brain ischemia, and 1 presented with acute subarachnoid hemorrhage.
  
  
  RESULTS
  Three wide-neck saccular aneurysms were almost completely coil occluded, leaving only small neck remnants that were intended to preserve the patency of incorporated MCA branches. The other 6 fusiform aneurysms were effectively treated by superficial temporal artery-MCA or occipital artery-MCA bypass, followed by complete coil occlusion of these aneurysms. Immediate angiograms and mid- or long-term neuroradiological imaging follow-up examinations revealed complete obliteration or near-complete occlusion (90%-99%) of the aneurysms in all 9 patients. Seven patients had a favorable long-term clinical outcome, and 1 patient died as a result of unrelated congestive heart failure. One patient required emergent surgical aneurysm thrombectomy because of inadvertent coil occlusion of the frontal opercular artery, which was not protected by the bypass, and the patient subsequently sustained a moderate neurological disability.
  
  
  CONCLUSIONS
  Giant MCA aneurysms with branch incorporations and other unfavorable features such as intraluminal thrombus, mural calcification, and fusiform configuration can be effectively treated with a team approach, using coil embolization after protective surgical bypass. When aneurysms with MCA branches incorporated into the neck rather than the dome are treated by endovascular techniques alone, long-term angiographic follow-up is necessary to assess and further treat any significant remnant.
authors.affiliation: Division of Interventional Neuroradiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles 90095-1721, California, USA. zhongsongshi@gmail.com
authors.forename: Zhong-Song
authors.initials: ZS
authors.lastname: Shi
authors.forename: Jordan
authors.initials: J
authors.lastname: Ziegler
authors.forename: Gary R
authors.initials: GR
authors.lastname: Duckwiler
authors.forename: Reza
authors.initials: R
authors.lastname: Jahan
authors.forename: John
authors.initials: J
authors.lastname: Frazee
authors.forename: James I
authors.initials: JI
authors.lastname: Ausman
authors.forename: Neil A
authors.initials: NA
authors.lastname: Martin
authors.forename: Fernando
authors.initials: F
authors.lastname: Viñuela
mesh_terms: D000328:Adult; D000368:Aged; D001921:Brain / Q000098:blood supply; D002533:Cerebral Angiography; D002548:Cerebral Revascularization / Q000379:methods*; D003131:Combined Modality Therapy / Q000295:instrumentation / Q000379:methods; D004621:Embolization, Therapeutic / Q000295:instrumentation* / Q000379:methods*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D020767:Intracranial Thrombosis / Q000209:etiology / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D010348:Patient Care Team / Q000458:organization & administration; D011183:Postoperative Complications / Q000209:etiology / Q000503:physiopathology; D019736:Prostheses and Implants; D019919:Prosthesis Implantation / Q000379:methods*; D013699:Temporal Arteries / Q000033:anatomy & histology / Q000601:surgery; D016896:Treatment Outcome