Partial Gyrus Rectus Resection as a Technique to Improve the Exposure to the Anterior Communicating Artery Complex through the Junctional Triangle: A Quantitative Study

Daniel Valli; Xiaochun Zhao; Evgenii Belykh; Qing Sun; Michael T. Lawton; Mark C. Preul

doi:10.1055/s-0040-1710517

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2021; 82(S 03): e211-e216
DOI: 10.1055/s-0040-1710517

Original Article

Partial Gyrus Rectus Resection as a Technique to Improve the Exposure to the Anterior Communicating Artery Complex through the Junctional Triangle: A Quantitative Study

Daniel Valli

¹Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States

,

Xiaochun Zhao

¹Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States

,

Evgenii Belykh

¹Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States

²Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia

,

Qing Sun

¹Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States

³Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China

,

Michael T. Lawton

¹Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States

,

Mark C. Preul

¹Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States

› Author Affiliations

Abstract

Objective The junctional triangle, formed by the distal A1 anterior cerebral artery (ACA) segment, the proximal A2 ACA segment, and the medial surface of gyrus rectus (GR), is a corridor of access to superiorly and posteriorly projecting anterior communicating artery (AComA) aneurysms that is widened by GR retraction or resection. Exposure of the AComA complex through the junctional triangle after GR resection has not been previously quantitatively evaluated.

Design GR resection extent and increase in artery exposure through the junctional triangle were assessed in this study.

Setting This study was conducted in the laboratory with a pterional approach, exposing the AComA complex.

Participants Ten sides of five cadaveric heads were considered.

Main Outcome Measures Exposure extent of ipsilateral and contralateral A1, A2, and AComA and accessibility of branches coming off the AComA complex were measured before and after GR resection. The GR was resected until sufficient bilateral A2 and contralateral A1 exposures were achieved. GR resection span was measured.

Results The mean (standard deviation) resected span of GR was 7 ± 3.9 mm. After GR resection, the exposed span of the ipsilateral A2 increased from 2 ± 0.7 mm to 4 ± 1.1 mm (p = 0.001); contralateral A2 exposure increased from 3 ± 1.5 mm to 4 ± 1.1 mm (p = 0.03). Contralateral recurrent artery of Heubner (RAH) and orbitofrontal artery were accessible in five and eight specimens, respectively, before GR resection and in all 10 after resection.

Conclusion GR resection improves exposure of bilateral A2 segments through the junctional triangle. Exposure improvement is greater for the ipsilateral A2 than contralateral A2. The junctional triangle concept is enhanced by partial GR resection during surgery for superior and posterior AComA aneurysms.

Keywords

anatomy - anterior communicating artery - anterior communicating artery aneurysm - gyrus rectus - junctional triangle - pterional - quantitative assessment

Full Text

References

References
1 Perlmutter D, Rhoton Jr AL. Microsurgical anatomy of the anterior cerebral-anterior communicating-recurrent artery complex. J Neurosurg 1976; 45 (03) 259-272
2 Molyneux AJ, Kerr RS, Yu LM. et al; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005; 366 (9488): 809-817
3 Kassell NF, Torner JC, Haley Jr EC, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 1990; 73 (01) 18-36
4 Solomon RA. , Department of Neurological Surgery TNI, Columbia University College of Physicians and Surgeons, New York, New York. Anterior communicating artery aneurysms. Neurosurgery 2001; 48 (01) 119-123
5 Figueiredo EG, Deshmukh P, Zabramski JM. et al. Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex. Neurosurgery 2005; 56 (02) 397-405
6 Sekhar LN, Natarajan SK, Britz GW, Ghodke B. Microsurgical management of anterior communicating artery aneurysms. Neurosurgery 2007; 61 (05, Suppl 2): 273-290
7 Diraz A, Kobayashi S, Toriyama T, Ohsawa M, Hokama M, Kitazama K. Surgical approaches to the anterior communicating artery aneurysm and their results. Neurol Res 1993; 15 (04) 273-280
8 Ivan ME, Safaee MM, Martirosyan NL. et al. Anatomical triangles defining routes to anterior communicating artery aneurysms: the junctional and precommunicating triangles and the role of dome projection. J Neurosurg 2019; 1: 1-12
9 Ribas GC. The cerebral sulci and gyri. Neurosurg Focus 2010; 28 (02) E2
10 Horikoshi T, Nukui H, Mitsuka S, Kaneko M. Partial resection of the gyrus rectus in pterional approach to anterior communicating artery aneurysms. Neurol Med Chir (Tokyo) 1992; 32 (03) 136-139
11 Böttger S, Prosiegel M, Steiger HJ, Yassouridis A. Neurobehavioural disturbances, rehabilitation outcome, and lesion site in patients after rupture and repair of anterior communicating artery aneurysm. J Neurol Neurosurg Psychiatry 1998; 65 (01) 93-102
12 Joo MS, Park DS, Moon CT, Chun YI, Song SW, Roh HG. Relationship between gyrus rectus resection and cognitive impairment after surgery for ruptured anterior communicating artery aneurysms. J Cerebrovasc Endovasc Neurosurg 2016; 18 (03) 223-228
13 Figueiredo EG, Deshmukh P, Zabramski JM. et al. Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex. Neurosurgery 2005; 56 (02) 397-405
14 Kempe LG, VanderArk GD. Anterior communicating artery aneurysms. Gyrus rectus approach. Neurochirurgia (Stuttg) 1971; 14 (02) 63-70
15 Yaşargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol 1975; 3 (01) 7-14
16 Yaşargil MG, Antic J, Laciga R, Jain KK, Hodosh RM, Smith RD. Microsurgical pterional approach to aneurysms of the basilar bifurcation. Surg Neurol 1976; 6 (02) 83-91
17 Rhoton Jr AL. The cerebrum. Neurosurgery 2002; 51 (04) S1-S51
18 Ramos A, Chaddad-Neto F, Joaquim AF. et al. The microsurgical anatomy of the gyrus rectus area and its neurosurgical implications. Arq Neuropsiquiatr 2009; 67 (01) 90-95
19 Agrawal A, Kato Y, Chen L. et al. Anterior communicating artery aneurysms: an overview. Minim Invasive Neurosurg 2008; 51 (03) 131-135
20 Almeida JP, Reghin Neto M, Chaddad Neto F, DE Oliveira E. Anatomical considerations in the treatment of intracranial aneurysms. J Neurosurg Sci 2016; 60 (01) 27-43
21 Hernesniemi J, Dashti R, Lehecka M. et al. Microneurosurgical management of anterior communicating artery aneurysms. Surg Neurol 2008; 70 (01) 8-28
22 Krayenbühl HA, Yaşargil MG, Flamm ES, Tew Jr JM. Microsurgical treatment of intracranial saccular aneurysms. J Neurosurg 1972; 37 (06) 678-686
23 Rhoton Jr AL, Perlmutter D. Microsurgical anatomy of anterior communicating artery aneurysms. Neurol Res 1980; 2 (3-4): 217-251
24 Spetzler RF, Sanai N. The quiet revolution: retractorless surgery for complex vascular and skull base lesions. J Neurosurg 2012; 116 (02) 291-300
25 Rhoton AJr. The supratentorial arteries. Neurosurg 2002; 51 (4 Suppl): S53-S120
26 Avci E, Fossett D, Aslan M, Attar A, Egemen N. Branches of the anterior cerebral artery near the anterior communicating artery complex: an anatomic study and surgical perspective. Neurol Med Chir (Tokyo) 2003; 43 (07) 329-333
27 Mavridis IN, Kalamatianos T, Koutsarnakis C, Stranjalis G. The microsurgical anatomy of the orbitofrontal arteries. World Neurosurg 2016; 89: 309-319