Double extra-intracranial microvascular anastomoses in deconstructive surgeries for giant aneurysms of internal carotid and middle cerebral arteries

Kobyakov N.G.; Lukshin V.A.; Pilipenko Yu.V.; Shulgina A.A.; Kondakov M.V.; Usachev D.Yu.

doi:https://doi.org/10.17116/neiro20258905116

Kobyakov N.G.

Burdenko Neurosurgical Center

ORCID: 0000-0001-5975-7188

Lukshin V.A.

Burdenko Neurosurgical Center

ORCID: 0000-0001-5787-484X

Pilipenko Yu.V.

Burdenko Neurosurgical Center

ORCID: 0000-0001-9916-722X

Shulgina A.A.

Burdenko Neurosurgical Center

ORCID: 0000-0002-2887-1583

Kondakov M.V.

Burdenko Neurosurgical Center

ORCID: 0009-0001-1121-4368

Usachev D.Yu.

Burdenko Neurosurgical Center;
Russian Medical Academy of Continuous Professional Education;
Botkin Hospital

ORCID: 0000-0002-9811-9442

Double extra-intracranial microvascular anastomoses in deconstructive surgeries for giant aneurysms of internal carotid and middle cerebral arteries

Authors:

Kobyakov N.G., Lukshin V.A., Pilipenko Yu.V., Shulgina A.A., Kondakov M.V., Usachev D.Yu.

More about the authors

Journal: Burdenko's Journal of Neurosurgery. 2025;89(5): 16‑27

DOI: 10.17116/neiro20258905116

Read: 297 times

To cite this article:

Kobyakov NG, Lukshin VA, Pilipenko YuV, Shulgina AA, Kondakov MV, Usachev DYu. Double extra-intracranial microvascular anastomoses in deconstructive surgeries for giant aneurysms of internal carotid and middle cerebral arteries. Burdenko's Journal of Neurosurgery. 2025;89(5):16‑27. (In Russ., In Engl.)
https://doi.org/10.17116/neiro20258905116

Подписка 2025 Журнал «Вопросы нейрохирургии» имени Н.Н. Бурденко (Burdenko's Journal of Neurosurgery)

Использование инфографики авторами научных работ

Close metadata

BACKGROUND

Deconstructive interventions with exclusion of the parent artery are one of the possible methods of treatment for giant and fusiform aneurysms of cerebral arteries if aneurysm occlusion with coils or insertion of flow-diverting stents are technically impossible. Such interventions are associated with high risks of stroke. In such cases, surgical revascularization with double barrel extra-intracranial bypass may be advisable to reduce the risks of ischemic complications, perioperative mortality and improve long-term neurological outcomes.

MATERIAL AND METHODS

The study included 25 patients with large and giant aneurysms of internal carotid (ICA) and middle cerebral arteries (MCA). All ones underwent double barrel bypass surgery with subsequent exclusion of aneurysm by endovascular or open method between 2015 and 2025.

RESULTS

The median follow-up was 11 [6; 25] months. Total exclusion of aneurysm was achieved in 24 (96%) patients. Ischemic complications occurred in 7 (28%) patients. The causes of ischemic complications were different: insufficient revascularization (n=3); EICMA thrombosis (n=1); ischemia in perforator basin (n=3). The risk of ischemic complications was higher in patients with aneurysms of MCA and supraclinoid segment of ICA compared to cavernous and paraclinoid localization.

CONCLUSION

Double barrel extracranial to intracranial bypass between superficial temporal artery and cortical M4 branches of MCA allows for sufficient revascularization and lower risks of ischemic complications following subsequent ICA occlusion for giant aneurysm. A personalized approach to choice of acceptor arteries taking into account localization of aneurysm and natural collateral circulation is necessary to achieve good functional outcomes.

Keywords:

double barrel bypass

giant aneurysms

fusiform aneurysms

deconstructive interventions

revascularization

Authors:

Kobyakov N.G.

Burdenko Neurosurgical Center

ORCID: 0000-0001-5975-7188

Lukshin V.A.

Burdenko Neurosurgical Center

ORCID: 0000-0001-5787-484X

Pilipenko Yu.V.

Burdenko Neurosurgical Center

ORCID: 0000-0001-9916-722X

Shulgina A.A.

Burdenko Neurosurgical Center

ORCID: 0000-0002-2887-1583

Kondakov M.V.

Burdenko Neurosurgical Center

ORCID: 0009-0001-1121-4368

Usachev D.Yu.

Burdenko Neurosurgical Center;
Russian Medical Academy of Continuous Professional Education;
Botkin Hospital

ORCID: 0000-0002-9811-9442

Received:

03.06.2025

Accepted:

18.07.2025

Close metadata

References:

Peeters SM, Colby GP, Kim WJ, Bae WI, Sparks H, Reitz K, Tateshima S, Jahan R, Szeder V, Nour M, Duckwiler GR, Vinuela F, Martin NA, Wang AC. Proximal Internal Carotid Artery Occlusion and Extracranial-Intracranial Bypass for Treatment of Fusiform and Giant Internal Carotid Artery Aneurysms. World Neurosurgery. 2023;180:e494-e505. https://doi.org/10.1016/j.wneu.2023.09.097
Santoro A, Armocida D, Paglia F, Iacobucci M, Berra LV, D’Angelo L, Cirelli C, Guidetti G, Biraschi F, Cantore G. Treatment of giant intracranial aneurysms: long-term outcomes in surgical versus endovascular management. Neurosurgical Review. 2022;45(6):3759-3770. https://doi.org/10.1007/s10143-022-01884-3
Eliava ShSh, Pilipenko YuV, Kholmatov MB, Belousova OB, Kheireddin AS, Okishev DN, Konovalov AnN, Grebenev FV. Microsurgical treatment of 723 cerebral aneurysms: a single-center prospective study. Burdenko’s Journal of Neurosurgery. 2025;89(3):60-67. (In Russ). https://doi.org/10.17116/neiro20258903160
Dzhindzhikhadze R, Bogdanovich I, Zaitsev A, Ermolaev A. How I do it: The microsurgical clipping of the giant paraclinoid aneurysm using the retrograde suction decompression technique. Acta Neurochirurgica. 2023;165(4): 1021-1026. https://doi.org/10.1007/s00701-023-05525-6
Xu BN, Sun ZH, Romani R, Jiang JL, Wu C, Zhou DB, Yu XG, Hernesniemi J, Li BM. Microsurgical management of large and giant paraclinoid aneurysms. World Neurosurgery. 2010;73(3):137-146; discussion e17, e19. https://doi.org/10.1016/j.surneu.2009.07.042
Meyers PM, Coon AL, Kan P, Dogan A, Bain M, Welch BG, Ebersole K, De Vries J, Wakhloo AK, Taussky P, Jenkins P, Hanel RA; SCENT Investigators. Five-year results of the SCENT trial with Surpass flow diverters to treat large or giant wide-neck aneurysms. Journal of NeuroInterventional Surgery. 2025:jnis-2024-022977. https://doi.org/10.1136/jnis-2024-022977
Hanel RA, Cortez GM, Lopes DK, Nelson PK, Siddiqui AH, Jabbour P, Pereira VM, István IS, Zaidat OO, Bettegowda C, Colby GP, Mokin M, Schirmer CM, Hellinger FR, Given C, Krings T, Taussky P, Toth G, Fraser JF, et al. Prospective study on embolization of intracranial aneurysms with the pipeline device (PREMIER study): 3-year results with the application of a flow diverter specific occlusion classification. Journal of NeuroInterventional Surgery. 2023;15(3):248-254. https://doi.org/10.1136/neurintsurg-2021-018501
Pilipenko YV, Eliava SS, Konovalov AN, Grebenev FV, Barchunov BV. The results of surgery for giant aneurysms of the middle cerebral arteries: a retrospective study. Almanac of Clinical Medicine. 2023;51(1):32-44. https://doi.org/10.18786/2072-0505-2023-51-005
Serbinenko FA, Filatov JM, Spallone A, Tchurilov MV, Lazarev VA. Management of giant intracranial ICA aneurysms with combined extracranial-intracranial anastomosis and endovascular occlusion. Journal of Neurosurgery. 1990;73(1):57-63. https://doi.org/10.3171/jns.1990.73.1.0057
Zhu W, Tian YL, Zhou LF, Song DL, Xu B, Mao Y. Treatment strategies for complex internal carotid artery (ICA) aneurysms: Direct ICA sacrifice or combined with extracranial-to-intracranial bypass. World Neurosurgery. 2011;75(3-4):476-484. https://doi.org/10.1016/j.wneu.2010.07.043
Arustamyan SR, Yakovlev SB, Shakhnovich AR, Krasnoperov IV, Sazonova OB, Bocharov AV, Bukharin EIu, Belousova OB, Kaftanov AN. Results of deconstructive endovascular surgeries in the treatment of large and giant intracranial aneurysms. Burdenko’s Journal of Neurosurgery. 2016;80(5):22-31. (In Russ). https://doi.org/10.17116/neiro201680522-31
Linskey ME, Jungreis CA, Yonas H, Hirsch WL, Sekhar LN, Horton JA, Janosky JE, Eskridge JM. Stroke risk after abrupt internal carotid artery sacrifice: Accuracy of preoperative assessment with balloon test occlusion and stable xenon-enhanced CT. American Journal of Neuroradiology. 1994;15(5):829-846.
Lukshin VA, Usachev DYu, Shulgina AA, Kulikov AS, Pronin IN, Batalov AI, Kobyakov NG. The first use of intraoperative MRI to study cerebral perfusion during surgical revascularization of the brain. Burdenko’s Journal of Neurosurgery. 2023;87(4):5-16. (In Russ). https://doi.org/10.17116/neiro2023870415
Doron O, Silverstein JW, Likowski D, Kohut K, Ellis JA. Temporary vessel occlusion in cerebral aneurysm surgery guided by direct cortical motor evoked potentials. Acta Neurochirurgica. 2022;164(5):1255-1263. https://doi.org/10.1007/s00701-022-05158-1
Devalckeneer A, Haddad G, Kuschcinski G, Leclerc X, Bourgeois P, Delhem N, Menovsky T, Aboukaïs R, Bretzner M. Virtual cut flow, an innovative noninvasive 4D ASL MRI biomarker of EIC bypass patency. Neurosurgical Review. 2025;48(1):1-8. https://doi.org/10.1007/s10143-025-03618-7
Cherian J, Srinivasan V, Kan P, Duckworth EAM. Double-barrel superficial temporal artery-middle cerebral artery bypass: Can it be considered “high-flow?”. Operative Neurosurgery. 2018;14(3):288-294. https://doi.org/10.1093/ons/opx119
Lukshin VA, Usachev DIu, Shul’gina AA, Shevchenko EV. Local cerebral hemodynamics following STA-MCA bypass in patients with symptomatic carotid occlusions. Burdenko’s Journal of Neurosurgery. 2019;83(3):29-41. (In Russ.). https://doi.org/10.17116/neiro20198303129
Shulgina AA, Lukshin VA, Shults EI, Batalov AI, Pronin IN, Usachev DYu. Assessment of cerebrovascular insufficiency with MR-ASL perfusion in patients with moyamoya angiopathy. Medical Visualization. 2021;25(2):102-115. (In Russ.). https://doi.org/10.24835/1607-0763-883