J Korean Neurosurg Soc.  2019 Nov;62(6):649-660. 10.3340/jkns.2019.0132.

Characteristics and Clinical Course of Fusiform Middle Cerebral Artery Aneurysms According to Location, Size, and Configuration

• Seo D
• Lee SU
• Oh CW
• Kwon OK
• Ban SP
• Kim T
• Byoun HS
• Kim YD
• Lee Y
• Won YD
• Bang JS

• KMID: 2463657
• DOI: http://doi.org/10.3340/jkns.2019.0132

Abstract

OBJECTIVE
To analyze the angiographic features and clinical course, including treatment outcomes and the natural course, of fusiform middle cerebral artery aneurysms (FMCAAs) according to their location, size, and configuration.
METHODS
We reviewed the literature on adult cases of FMCAAs published from 1980 to 2018; from 25 papers, 112 FMCAA cases, for which the location, size, and configuration could be identified, were included in this study. Additionally, 33 FMCAA cases in our hospital were included, from which 16 were assigned to the observation group. Thus, a total of 145 adult FMCAA cases were included. We classified the FMCAAs according to their location (l-type 1, beginning from prebifurcation; l-type 2, beginning from bifurcation; l-type 3, beginning from postbifurcation), size (small, <10 mm; large, ≥10 mm; giant, ≥25 mm), and configuration (c-type 1, classic dissecting aneurysm; c-type 2, segmental ectasia; c-type 3, dolichoectatic dissecting aneurysm).
RESULTS
The c-type 3 was more commonly diagnosed with ischemic symptoms (31.8%) than hemorrhage (13.6%), while 40.9% were found accidentally. In contrast, c-type 2 was more commonly diagnosed with hemorrhagic symptoms (14.9%) than ischemic symptoms (10.6%), and 72.3% were accidentally discovered. According to location, ischemic symptoms and hemorrhage were the most frequent symptoms in l-type 1 (28.6%) and l-type 3 (34.6%), respectively. Most of l-type 2 FMCAAs were found incidentally (68.4%). Based on the size of FMCAAs, only 11.1% of small aneurysms were found to be hemorrhagic, while 18.9% and 26.0% of large and giant aneurysms were hemorrhagic, respectively. Although four aneurysms of the 16 FMCAAs in the observation group increased in size and one aneurysm decreased in size during the observation period, no rupture was seen in any case and there were no significant predictors of aneurysm enlargement. Of 104 FMCAAs treated, 14 cases (13.5%) were aggravated than before surgery and all the aggravated cases were l-type 1.
CONCLUSION
While ischemic symptoms occurred more frequently in l-type 1 and c-type 3, hemorrhagic rather than ischemic symptoms occurred more frequently in l-type 3 and c-type 2. In case of l-type 1 FMCAAs, more caution is required in determining the treatment due to the relatively high complication rate.

Keyword

Aneurysm, Dissecting; Fusiform aneurysm; Middle cerebral artery; Natural history

MeSH Terms

Adult
Aneurysm
Aneurysm, Dissecting
Dilatation, Pathologic
Hemorrhage
Humans
Intracranial Aneurysm*
Middle Cerebral Artery*
Natural History
Rupture

Figure

• 

  Fig. 1. Classification according to location of FMCAAs. l-type 1a, located only at prebifurcation; l-type 1b, beginning from prebifurcation to postbifurcation; l-type 2a, located only at bifurcation; l-type 2b, beginning from bifurcation to postpostbifurcation; l-type 3a, beginning from postbifurcation and mainly located on M2; l-type 3b, mainly located after M3 or M3. FMCAA : fusiform middle cerebral artery aneurysm.

• 

  Fig. 2. Classification according to configuration of FMCAAs. A : c-type 1, classic dissecting aneurysm. B : c-type 2, segmental ectasia. C : c-type 3, dolichoectatic dissecting aneurysm. FMCAA : fusiform middle cerebral artery aneurysm.

• 

  Fig. 3. Characteristics according to location of FMCAAs. A : Frequency of occurrence of FMCAAs according to location. B : Distribution ratio of size of FMCAAs by location. C : Distribution ratio of configuration of FMCAAs by location. D : Clinical presentation according to location of FMCAAs. FMCAA : fusiform middle cerebral artery aneurysm.

• 

  Fig. 4. Characteristics according to location and size of FMCAAs. A : Frequency of occurrence of FMCAAs according to configuration. B : Distribution ratio of size of FMCAAs by configuration. C : Clinical presentation according to configuration of FMCAAs. D : Clinical presentation according to size of FMCAAs. FMCAA : fusiform middle cerebral artery aneurysm.

• 

  Fig. 5. Case 1, 67-year-old woman. A and C : MRI and TFCA revealed that the FMCAA (white arrow) was classified as l-type 2a and c-type 3, and the maximum diameter was 19 mm. B : After 83 months, the occlusion of middle branch of postbifurcation MCA (white arrow) was found on TFCA. D and E : MRI showed the increased size of thrombosed aneurysm (white arrow) to 22 mm and detected the acute infarction (arrowhead) in the temporal lobe. MRI : magnetic resonance imaging, TFCA : transfemoral carotid angiography, FMCAA : fusiform middle cerebral artery aneurysm, MCA : middle cerebral artery.

• 

  Fig. 6. Case 2, 50-year-old woman. A and B : A thrombosed fusiform aneurysm (white arrow) with maximum diameter of 18 mm was diagnosed and was classified as l-type 3a and c-type 3. C and D : One year later, the maximum diameter increased to 25 mm and distal artery occlusion was observed because of increased size of thrombus (white arrow).

• 

  Fig. 7. Case 3, 72-year-old man. A and B : FMCAA, classified as l-type 2a and c-type 2, was detected on TFCA and MRI (white arrow), and maximum dimeter was 15 mm. C and D : After 49 months, the maximum diameter increased to 18 mm (white arrow), but there was no rupture of aneurysm for 8 years until recently. FMCAA : fusiform middle cerebral artery aneurysm, TFCA : transfemoral carotid angiography, MRI : magnetic resonance imaging.

Reference

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