MCA wide neck lobar shape berry aneurysm, involving M1,M2,M3, how to treat?

47 years old man, spontaneous intracranial hemorrhage underwent unsuccessful open surgery for clipping right MCA aneurysm, closed and re-bleeding again, transferred to our hospital for further management.

Diagnostic angiography performed subsequently, found a lobar shape wide neck aneurysm noted in the right MCA involving spenoidal segment, insular segment and opercular segment namely M1, M2 and M3.

3D image acquired and showed as follow:

I'm planning to treat this patient with stent assist technique to coil the aneurysm, my treatment plan is attached in the attachement file for your reference. Any comment or suggestion?

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Comment by Karam Chand Sharma on June 23, 2010 at 10:19am
Dear Kuok,
Neurosurgeons are comfortable because of neuro-interventionist. By doing coiling and embolisation great no of patients have benefitted. Surgery is afterall a major procedure and still carries mortality and morbidity. By the look of postoperative CT scan patient is lucky that it is on right side and therefore speech is spared. After all without retracting you can not reach these aneurysms. Few advantages of surgery like clearing subarachnoid blood, carotid sympathectomy, third ventriculostomy can not outweigh intravascular approaches. The debate about surgery versus coiling should end, since it is quite conclusive that surgery has more morbidity. I forsee more simpler approaches in future, since coiling is expensive and involves catheterisation of parent vessel and quite a few complications like rupture, distal migration, incomplete obliteration of aneurysm are direct result of the procedure. With a 3D intraoperative imaging a material could be developed which could be placed all around the aneurysm, hardening over a period of half an hour or so, without obliterating lumen of vessel and perforators etc. This material could be placed either with stereotaxy or image guided system. This I say is possible because aneurysms rarely cause mass effect. See a picture of giant aneurysm arising from mca branch, posted by me in theneuronetwork.com.
Become a member of neurosurgic.com and post some pictures there also.
Comment by Kuok Cheong U on June 23, 2010 at 4:29am
Dear Karam,
You are right, I don't think microanastomsis work, so I planned to treat this case with endovascular method, stent assist GDC technique, what do you think?
Best regards,
Kuok
Comment by Karam Chand Sharma on June 20, 2010 at 3:11am
Dear Kuok,
You have put up nice images again. One of the method desribed by L.Shekhar could be relocating branches of MCA on M1 but that involves lot of experience in microanastamosis. I did a STA-MCA anastamosis few days back and I know how hard is it to take sutures from small vessels. Other message could be the amount of trauma inflicted on brain by surgery as is evident in this postoperative CT scan

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