Emory Stroke Center specializes in an array of interventions for patients with all types of neurovascular disorders 

The Emory Department of Neurosurgery established the first multidisciplinary stroke center in the region to include neurosurgeons, interventional neuroradiologists, stroke neurologists and neurocritical care specialists. As part of the comprehensive Emory Brain Health Center, the goals were to integrate expertise across multiple medical and surgical specialties and to provide the best individualized care for patients presenting with all types of neurovascular disorders, including ischemic and hemorrhagic stroke.

Today the Emory Stroke Center manages the largest number of patients with aneurysms, arteriovenous and other vascular malformations, and spinal malformations in the region and is one of the largest stroke centers in the country. Our outcomes for managing ischemic and hemorrhagic stroke are the best in the region and among the nation’s best. By working in a highly integrated and collegial fashion, we provide individualized care determined to be optimal for each patient.

Case Background

In 2018, a 33-year-old male presented to a hospital in Tennessee with severe headache. There, the care team discovered a large right middle cerebral artery (MCA) aneurysm on the M1 segment. They treated the MCA aneurysm with endovascular coiling.

CT angiogram performed at the time of initial treatment

In October 2020, the patient developed progressively worsening headaches and weakness in his left upper extremity. Computed tomography demonstrated a nearly 5 cm mass in the right frontal lobe in the region of the previously coiled and partially thrombosed aneurysm. Imaging indicated a 1.5 cm midline shift and dilatation of the right lateral and third ventricles.

Diagnostic Evaluation

The patient was transferred to the Emory University Hospital neuro-critical care unit and was neurologically intact other than a right facial droop. The neurosurgery team placed a right frontal ventriculostomy to manage his trapped ventricles.

CT at time of presentation to Emory

Michael Cawley, MD, director of the Emory Stroke Center, performed a diagnostic cerebral angiogram which demonstrated a mostly thrombosed and partially coiled right MCA aneurysm with a small pocket of residual filling at the neck and severe stenosis of the MCA distal to the residual neck. 

Cerebral angiogram with red dots outlining the thrombosed portion of the aneurysm

Following the discussion of a variety of therapeutic options, including some of the latest endovascular techniques available, the multidisciplinary stroke team determined that further endovascular therapy was unlikely to be successful. A plan was established to revascularize the MCA with a high-flow bypass and to clip the MCA distal to the aneurysm neck but proximal to the lenticulostriate arteries. This procedure would create a “blind sac” that would thrombose completely.

Surgical plan was to perform a high flow bypass to the MCA (arrow) and occlude the MCA distal to the aneurysm and proximal to the lenticulostriates (bar)

Surgery

At surgery, Daniel Barrow, MD, chief of the neurosurgery service at Emory Healthcare, performed a right frontotemporal craniotomy to expose the MCA and aneurysm. The right radial artery was harvested to serve as a bypass conduit and the right cervical carotid artery was exposed for the proximal bypass. After harvesting, the radial artery was tunneled from the neck, over the zygomatic arch, to the Sylvian fissure, where it was anastomosed to an M2 branch of the MCA.

The proximal radial artery was then anastomosed in an end-to-side fashion to the common carotid artery; therefore, establishing an alternate blood flow source to the right hemisphere. At this point, the aneurysm was exposed through the Sylvian fissure and a permanent aneurysm clip placed immediately distal to the aneurysm neck on the M2, taking care to position it proximal to the lenticulostriate arteries. Thus, the partially thrombosed aneurysm became a “blind sac.”

Intraoperative angiography documented excellent filling through the bypass and minimal residual filling of the aneurysm through anterograde flow.

The patient did well following surgery with no new neurological deficits. He was unable to be weaned off his ventriculostomy and underwent a ventriculoperitoneal shunt. A follow-up angiogram was performed a month after surgery and demonstrated wide patency of the bypass and complete occlusion of the aneurysm. At the most recent follow-up appointment, the patient was neurologically intact without complaint.

Surgical plan was to perform a high flow bypass to the MCA (arrow) and occlude the MCA distal to the aneurysm and proximal to the lenticulostriates (bar)

Discussion

Minimally invasive endovascular options hold great promise for many patients; however, they need to be considered as carefully as we consider microsurgical options. Despite remarkable advances in endovascular therapy, there are many intracranial aneurysms for which even the latest endovascular options are not sufficient. Microsurgery is often required for complex aneurysms, including those with:

• Wide necks
• Large size
• Dolichoectatic morphology
• Intraluminal thrombus
• Previous endovascular therapy
• Atherosclerotic walls

For many of the conditions cerebrovascular neurosurgeons treat, surgery may remain the best and sometimes only choice; however, it is essential to have a truly multidisciplinary team to consider various therapeutic options and deliver the best treatment for each patient and their neurovascular disorder.

Emory Brain Health Center is committed to the continued health and safety of all patients. During this time, we are taking all necessary precautions to screen for COVID-19 and to prevent its potential spread. We continue to monitor the evolving COVID-19 pandemic and are working with experts throughout Emory Healthcare to keep your patients safe. For the most up-to-date information for our referring partners, click here.