12. 中大脳動脈瘤 (M<SUB>1</SUB> 末稍部) に対するDistal Approach

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The ordinary approach to bifurcation aneurysm of middle cerebral artery mainly recommended is as follows. Ipsilateral internal carotid artery was identified at first, then the stem of middle cerebral artery was followed distally to keep Ml, M<SUB>2</SUB> and neck of aneurysm. This approach is, however, not suited for aneurysm which projected rostrally or laterally from M1 and attached to dura mater. Because, premature rupture may occur before finding internal carotid artery by the retraction of middle cerebral artery. We prefer to use another method, called distal approach, for such cases. Using this approach it is easy to keep distal M1, proximal M2 and aneurysmal neck. Technically, sylvian fissure is opened about 2-3 cm long distally from aneurysm and the branches of middle cerebral artery are followed proximally to distal M1. Once the distal M1 and proximal M2 are identified, the neck of aneurysm is easily treated. The indication of this approach is decided by CAG findings. When the projection of aneurysm is laterally or inferiorly from M2 at AP view and is obviously rostrally from M1 and M2 at lateral view, it is good indication of this approach. Especially, when the top of the aneurysm is thought to attach to dura matter, it is the absolute indication. By our experiences, the lateral view findings seem to be more useful. During a 15-year period, distal approach was used in 48 of 111 cases of ruptured bifurcation aneurysm and premature rupture was seen in only one case. It is necessary neither cortical incision nor parenchymal resection for treatment of bifurcation aneurysm of middle cerebral artery.
The Japanese Society on Surgery for Cerebral Strokeの論文

12. 中大脳動脈瘤 (M<SUB>1</SUB> 末稍部) に対するDistal Approach

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