title: Multiple reimplantation technique for treatment of complex giant aneurysms of the middle cerebral artery: technical note.
abstract: BACKGROUND
  Giant middle cerebral artery (MCA) aneurysms are among the most challenging neurovascular lesions, especially when the M2 and M3 branches are incorporated into the aneurysm. Here we report on two cases with complex MCA aneurysms, in which double and triple arterial reimplantation of the efferent vessels into a saphenous vein graft (SVG) was applied to reconstruct the MCA tree, allowing final trapping of the aneurysm.
  
  
  METHODS
  In the first case, a 41-year-old woman presented with a partially thrombosed giant MCA aneurysm including three efferent branches. Two superior trunks were disconnected and reimplanted onto an SVG fed by the external carotid artery (ECA). Following anastomosis between the SVG and the inferior trunk, the aneurysm was trapped. The second case is a 67-year-old man with recurrent giant MCA aneurysm incorporating two efferent M2 branches. First, the superior trunk was reimplanted onto an SVG, then the SVG was anastomosed to the inferior trunk. Finally the afferent M1 was clipped. Intraoperative indocyanine green (ICG) videoangiography (FLOW 800) was used for studying bypass patency.
  
  
  RESULTS
  In both cases, successful bypass patency was demonstrated by ICG videoangiography. Postoperative digital subtraction angiography (DSA) confirmed bypass patency. The first case was discharged without any neurological deficit. The second case suffered from bleeding due to refilling of the aneurysm via the inferior M2. An additional clip was placed on the inferior M2 in a second step. The patient was discharged with weakness of the left arm.
  
  
  CONCLUSIONS
  Reconstructing an MCA bifurcation or trifurcation combining multiple arterial reimplantation is effective for treatment of selective cases of complex MCA aneurysms.
authors.affiliation: Department of Neurosurgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
authors.forename: Naoki
authors.initials: N
authors.lastname: Kato
authors.forename: Vincent
authors.initials: V
authors.lastname: Prinz
authors.forename: Tobias
authors.initials: T
authors.lastname: Finger
authors.forename: Markus
authors.initials: M
authors.lastname: Schomacher
authors.forename: Julia
authors.initials: J
authors.lastname: Onken
authors.forename: Julius
authors.initials: J
authors.lastname: Dengler
authors.forename: Wibke
authors.initials: W
authors.lastname: Jakob
authors.forename: Peter
authors.initials: P
authors.lastname: Vajkoczy
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D002548:Cerebral Revascularization / Q000379:methods*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D008297:Male; D008866:Microsurgery; D012092:Replantation; D012501:Saphenous Vein / Q000637:transplantation*