Left MCA Aneurysm

Contributor:

Dr. Winston Gittens

Consultants:

Dr. Mike Tymianski
Dr. Fred Gentili
Dr. John Wong
Dr. J Max Findlay
Dr. Chris Ekong
Dr. Gary Steinberg
Dr. Joseph Buwembo
Dr. D Sutherland
Dr. R Willinsky
Dr. Karel terBrugge

Case 34

Age: 53

Sex: Male

History: Summer 2006: Transient impairment of right hand function (motor) lasted 10 minutes. No head

Nohistory to suggest subarachnoid haemorrhage.

May 17, 2007 - Dr. Winston Gittens, Neurosurgeon, New Westminster

Past History:

- Hypertension

- Asbestos

- Chronic neck pain

- Smoker & drinker (not heavy)

Since then:

- Intermittent dizzines

- One episode of blurred vision

- One episode of speech impairment "garbled"

Family History:

- Positive for aneurysm

- Mom died post-op following surgery for cerebrovascular problem (possible CVA)

Physical Examination:

Neurologically unremarkable except for reduced left biceps and both ankle jerks.

May 17, 2007 - Dr. Chris Ekong, Neurosurgeon Regina

To Medi-Fax Neurovascular consultants:

Winston would appreciate your comments, please.

Chris

May 23, 2007 - Dr. G Sutherland, Neurosurgeon, Calgary

Dear Chris,

John Wong and I have reviewed the case. In summary, a 53 year old man with appears to be either a TIA or focal seizure. Given his pathology, we favor the former.

The images show a calcified partially-thrombosed left MCA aneursym that has incorporated both daughter branches.

We recommend a baseline MRI, blood pressure control, aspirin, and serial followup with MRI. We suspect his risk for rupture is well below the risk of treatment i.e. ECIC bypass with Hunterian ligation of parent vessel.

Best regards,

Garnette and John

May 23, 2007 - Dr. Ryojo Akagami, Neurosurgeon

Hi Chris

thanx for sending this case for me to take a look at.

As you know, I don't get to treat aneurysms and I don't see aneurysms through the office - my secretary just sends it to Gary or Charles... but if I had to make a comment, I think this patient is having TIA's related to the aneurysm and just needs to be on ASA and followed. If the aneurysm grew/bled, it's little more distal and may tolerate occulsion with sacrafice of the vessel endovascualrly - could do a test occlusion prior. If it fails test occlusion, clip occlusion and bypass - I'd do a sta or rad artery bypass from an extracranial branch rather than a jump graft or reimplantation on the dominant side (risk to donor vessel), also may need to fashion a 'Y' to the end of the radial artery graft, or one end to end and one end to side (depending on anatomy) since there appears to be two vessels distally that will need blood.

STA and radial artery would also work....

Ryojo

Dr. Ryojo Akagami

May 24, 2007 - Dr. Mike Tymianski, Neurosurgeon, Toronto

I have just treated a similar case on Monday.

My opinion in brief: symptomatic, large aneurysm. Risks include hemorrhage (as it is >1cm), and embolic events (as already noted in this patient).

Also, familial aneurysms raise concerns further. Thus, I would favor treatment.

I am not familiar with a good endovascular option for most such cases.

However, a proximal test balloon occlusion sometimes reveals sufficiently decent collateralization to enable treatment with proximal occlusion alone.

Surgically - clipping is unlikely to work as this is a fusiform, partly calcified, partly thrombosed aneurysm. I recommend proximal occlusion or trapping (provided there are no perforators). This would require an EC-IC bypass to the distal 2 MCA branches in order to spare the distal brain. This can be achieved by anastomosing the temporal and frontal branches of the STA end-to-end to the distal MCA branches as they take off from the aneurysm.

Sometimes, an interposition graft may be needed, and therefore should be prepared for at the time of surgery.

Best

Mike Tymianski

May 24, 2007 - Dr. Robert Willinski, Neurosurgeon, Toronto

Chris,

Calcified , fusiform aneurysm presenting with a single TIA 10 months ago.

Etiology is unclear but includes old dissection, healed inflammatory process, developmental dysplasia. Natural history not known. I favour as conservative approach and ASA with a strong message to stop smoking.

Best regards,

Bob

May 25, 2007 - Dr. Max Findlay, Neurosurgeon, Edmonton

I gather Winston will get this? Greetings.

I have not seen what the other experts think, and I think you'll get various opinions, but with a weird, dysplastic and quite calcified fusiform aneurysm (that's been there a long time) on a distal (M2 I think) MCA branch that caused only a TIA a long time ago, I think an intervention (which would have to be some type of trapping and distal bypass, challenging fun, granted) would be unjustifiably hazardous, and more dangerous than the natural history of the lesion. This is not a saccular aneurysm, and while not without a risk of bleeding, my hunch the risk is lower than the numbers we usually throw around. I would have him take an aspirin a day and follow this lesion in a year. Can't make him any better than he is!

Max

May 25, 2007 - Dr. Mike Tymianski, Neurosurgeon, Toronto

Attached are films of the similar case I referred to. Fusiform distal LICA aneurysm. Not as large as case 34. Treated with Lt STA-MCA bypass to the MCA distal to the aneurysm, followed by trapping of the aneurysm.

Best

MT

May 26, 2007 - Dr. Gary K. Steinberg, Neurosurgeon, Stanford

Chris: This is a complicated fusiform, calcified and partially thrombosed dominant hemisphere MCA aneurysm. Although the patient is relatively young (2 years younger than me), he is minimally symptomatic (1 brief motor TIA), I would put him on an antiplatelet agent and follow him clinically and with CTAs. ISUIA did not address these type of aneurysms. Not sure the natural history of this aneurysm at 53 yo is worse than the surgical risks. Don't think any endovascular options would work.

Gary

May 26, 2007 - Dr. Karel Terbrugge, Neuroradiologist, Toronto

Agree with previous comments (except MT). The natural history of this

particular type of aneurysm is highly unclear. Most of them appear to be very stable and have no propensaty to bleed or enlarge. I agree with MT that if this patient were to show evidence of clinical or imaging worsening then at that time surgical management should be considered. For the moment ASA is good choice with lower risk for morbidity then complex surgery.

Regards. KTB

May 26, 2007 - Dr. Mike Tymianski, Neurosurgeon, Toronto

Dear all:

Note that, in the case of medical problems for which the natural history is unclear but believed to be less aggressive in the short-term (e.g., 1-2% per year bleed rate such as is believe with some aneurysms), it is easiest to appear to have the correct answer by taking a conservative stance. Usually, our attention span for the given case is shorter than the time during which untoward consequences may become manifest for the patient.

While I agree that the natural Hx for this particular aneurysm is unclear, I do not agree that it is likely to be benign. Though we can each anecdotally recall fusiform, hard to treat dissecting aneurysms that we left untreated (because we had nothing to offer), there are an equal number of anecdotes for such aneurysms not resolving, growing, or bleeding (most commonly in the posterior fossa). Unfortunately, due to the attention-span problem referred to above, we have not looked critically at our series of patients, and our opinions remain anecdotal.

Sadly, our opinions also remain inconsistent, as the patient I recently treated surgically with a similar problem was conferenced by our entire team here at UHN, including those who elected for a conservative approach for Case 34, and the consensus then was to treat...

I remain concerned about this lesion in a relatively young, previously symptomatic patient with a family history of aneurysms.I think that the patient should be informed of the controversy surrounding their case, as patients must participate in the decision making. I would still inform them that, in this case, the aneurysm is treatable. I agree wholeheartedly that if the patient prefers a conservative stance, imaging and clinical follow up would be paramount, and interesting. However, as we know, many aneurysms with which we are more comfortable in connection with natural history do not have to grow in order to bleed, and personally, I'd prefer not to bleed intracranially while on antiplatelet agents.

Chris - great case. Keep-em coming. It's great to see these controversies in a Canada-wide forum...

Best Regards to all,

Mike Tymianski

May 27, 2007 - Dr. Fred Gentili, Neurosurgeon, Toronto

Hi Chris,

Sorry for late response but just back from China.

Arguments for both conservative and surgical treatment valid based on our current limited knowledge of the true natural history of this type of lesion. I would initially pursue a conservative approach with antiplatelet medication but would consider treatment if she has recurrent symptoms. Agree with Mike T that patient should be fully informed of the issues and options and indeed she may make the final decision.

Fred

May 29, 2007 - Dr. Chris Ekong, Neurosurgeon Regina

Dear Group:

You have been a great team. Your responses have been sent to Winston. For now, patient is on ASA. 306 Neurosurgeons and others wordwide have been pointed to this case. It seems to be a good forum for open discussion. Keep the cases coming.

Thanks.

Chris

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