A Modified Direct Suction Decompression Strategy for Complex Middle Cerebral Artery Bifurcation Aneurysms in the Endovascular Era: Technical Note and Literature Review.

Abstract

Direct suction decompression facilitates the clipping of complex middle cerebral artery (MCA) bifurcation aneurysms; however, with conventional direct puncture, intermittent reperfusion is limited after dome puncture, and the setup can crowd the operative corridor. We report our initial experience with bypass-assisted stump isolation with controlled suction (BASICS), a modified technique. In direct puncture, after a double-barrel extracranial-intracranial bypass to the efferent branches, decompression is achieved under temporary trapping by direct needle puncture connected to suction. In BASICS, a single EC-IC bypass is constructed into a dome-originating efferent branch, which is divided from the aneurysm, and suction is applied through the aneurysm-side stump under temporary trapping, allowing controlled, repeatable decompression during reconstructive clipping. We retrospectively reviewed data of patients with complex MCA bifurcation aneurysms treated with suction decompression and assessed the intraoperative findings, complications, and outcomes. Four patients underwent direct suction decompression: conventional (n = 3) and BASICS (n = 1). In direct puncture cases, lateral lenticulostriate arteries were identified only after the first clip, whereas BASICS allowed identification before initial clip placement. Two perioperative events occurred in the direct puncture group (perforator territory infarction and transient motor aphasia). Aneurysms did not recur observed during follow-up. BASICS may mitigate the limitations of puncture-based suction decompression by enabling controlled and repeatable decompression and facilitating stepwise reconstructive clipping in selected complex MCA bifurcation aneurysms. When needed, conversion to a sidewall configuration may expand the multimodal options, including staged endovascular adjuncts. These potential advantages are hypothesis-generating, warranting further validation.