Fusiform middle cerebral artery aneurysm treatment

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Combined treatment of endovascular and bypass surgery can successfully treat large or giant complex fusiform middle cerebral artery aneurysm ¹⁾

Intracranial fusiform aneurysm treatment depends on several factors, including the location, size, and rupture status of the aneurysm, as well as the overall clinical condition of the patient.

### Treatment Approaches:

1. Conservative Management:

1. In some cases, fusiform aneurysms that are unruptured and asymptomatic may be monitored conservatively with regular imaging (CT angiography or MRI) to track changes in size or any development of symptoms. However, conservative management is not often the first-line approach in cases with a risk of rupture or symptomatic aneurysms.

2. Endovascular Treatment:

1. Coiling:
   1. This is the most common endovascular treatment for fusiform MCA aneurysms. A catheter is inserted through the femoral artery and navigated to the aneurysm site. Coils (platinum or other materials) are deployed into the aneurysmal sac to promote clot formation and seal off the aneurysm from circulation.

1. While coiling is effective in treating saccular aneurysms, its application in fusiform aneurysms can be challenging because of the diffuse nature of the aneurysm. Complete embolization is often difficult, and recurrence of the aneurysm is a concern.

- Flow Diversion:

- Flow-diverting stents, such as the Pipeline embolization device, have become a promising treatment option for fusiform aneurysms. These stents redirect blood flow away from the aneurysm, allowing for thrombosis and eventual resolution of the aneurysm over time.

1. This method is particularly beneficial in cases where other forms of embolization might not be suitable or in aneurysms with a wide neck or complex geometry.

1. Use of Detachable Balloons and Other Devices:

1. Occasionally, detachable balloons or other specialized devices may be used in conjunction with coiling or stenting to occlude the aneurysm more effectively, particularly in the case of giant or complex fusiform aneurysms.

3. Microsurgical Treatment:

1. In cases where endovascular techniques are not feasible or fail to provide a satisfactory result, microsurgical approaches may be considered. Surgical strategies for fusiform aneurysms include:

1. Bypass Surgery: If the aneurysm is in a critical area or involves a large segment of the MCA, a bypass surgery may be necessary to reroute blood flow and prevent ischemic complications.

1. Aneurysm Resection: In rare cases, the aneurysm may be surgically excised, although this is often technically difficult and associated with higher risks of complications.

1. Clip Application: In some instances, a clip may be applied to isolate the aneurysm, but this is less commonly performed for fusiform aneurysms compared to saccular aneurysms due to the complex anatomy.

4. Follow-Up and Long-Term Management:

1. After treatment, the patient requires regular follow-up with neuroimaging to monitor for any recurrence of the aneurysm or complications such as rebleeding or ischemia. This may involve serial CT angiograms or MRIs.

1. In cases treated with stents or flow-diverting devices, the patient should be on dual antiplatelet therapy to prevent thrombotic complications.

1. In patients with persistent neurological deficits or significant complications following treatment, rehabilitation, and further interventions may be needed.

### Challenges in Fusiform Aneurysm Treatment:

1. Complex Anatomy: Fusiform aneurysms have a more complex structure compared to saccular aneurysms, which can complicate both endovascular and surgical treatment options.

1. Incomplete Occlusion: Achieving complete occlusion of the aneurysm, especially the neck, can be difficult, and there is a higher risk of aneurysm recurrence or rebleeding.

1. Complications: Potential complications include vessel rupture, ischemic stroke, coil migration, stent thrombosis, and infections related to the procedure.

Stent-assisted coiling of fusiform middle cerebral artery aneurysm treatment

Conclusion:

The treatment of fusiform MCA aneurysms requires a tailored approach based on the specific characteristics of the aneurysm and the patient’s clinical condition. Endovascular methods, including coiling with stent assistance or flow diversion, are the most common treatments, with good outcomes in many cases. However, due to the complexity of fusiform aneurysms, some cases may require surgical intervention or a combination of strategies. Regular follow-up and monitoring are essential for ensuring a favorable long-term prognosis and preventing complications.