The Art of Cerebral Revascularization: An Illustrative Case Series of Bypass Techniques for Complex Intracranial Aneurysms

José Luis Acha Sánchez; Jhon E Bocanegra-Becerra; Arturo J Ruiz-Yaringaño; Diego Hidalgo Avendaño; Andrea Celeste Cifuentes Hoyos; Miriam Lizeth Guerrero Yrene; Aaron Rodriguez-Calienes

doi:10.1016/j.wneu.2024.04.170

The Art of Cerebral Revascularization: An Illustrative Case Series of Bypass Techniques for Complex Intracranial Aneurysms

World Neurosurg. 2024 May 6:S1878-8750(24)00743-5. doi: 10.1016/j.wneu.2024.04.170. Online ahead of print.

Authors

José Luis Acha Sánchez¹, Jhon E Bocanegra-Becerra², Arturo J Ruiz-Yaringaño³, Diego Hidalgo Avendaño⁴, Andrea Celeste Cifuentes Hoyos⁴, Miriam Lizeth Guerrero Yrene⁵, Aaron Rodriguez-Calienes⁶

Affiliations

¹ Vascular Neurosurgery and Skull Base Division, Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru; School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru.
² School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru. Electronic address: jhon.bocanegra.b@upch.pe.
³ School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru; "San Fernando" Scientific Society, Lima, Peru.
⁴ School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
⁵ Scientific Society "Universidad Nacional Pedro Ruiz Gallo", Chiclayo, Peru.
⁶ Department of Neurology, University of Iowa Hospitals and Clinics, IA, USA.

PMID: 38719076
DOI: 10.1016/j.wneu.2024.04.170

Abstract

Introduction: Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long-standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs.

Methods: The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru during 2018-2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications.

Results: Seventeen patients (70.59% female; median age: 53 years) with 17 CIAs (64.7% saccular; 76.5% ruptured) were included. The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first, second, and third-generation bypass. In 47.1% of cases, an anastomosis between the superior temporal artery (STA) and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), STA-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). The intraoperative aneurysm rupture rate was 11.8%. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10-15). At the six-month follow-up, 82.4% of patients had a modified ranking scale (mRS) score ≤2, bypass patency was present in all cases, and the morbidity rate was 17.6%.

Conclusion: CIAs represent a spectrum of defiant vascular lesions with a poor natural history. Bypass surgery offers the potential for definitive treatment. Our case series illustrated the predominant role of cerebral revascularization of CIAs with a critical case-by-case approach to provide optimal outcomes in a limited-resource setting.

Keywords: Brain Aneurysm; Bypass; Cerebral Revascularization; Complex Intracranial Aneurysms; Microsurgery.