PMC7749952_01
Preoperative imaging. (a-c) Magnetic resonance angiography (MRA) showed an unruptured aneurysm of anterior communicating artery, 7 mm in maximum diameter (a), which was protruding upward (b) and located over 10 mm above the frontal base (c). (d and e) M3 portion of middle cerebral artery was occluded in MRA (e, arrow) performed just after the three-dimensional digital subtraction angiography (3D-DSA), which was patent in 3D-DSA (d, arrowhead). (f) No cerebral infarction in diffusion-weighted imaging.
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F1
The ACoA aneurysm had a maximum diameter of 7 mm [Figure 1a]. Because the aneurysm was protruding upward, located over 10 mm above the frontal base [Figure 1b and c], we planned to clip the ACoA aneurysm through an interhemispheric approach. MRI/A was performed 10 min after the onset, and magnetic resonance angiography (MRA) revealed left M3 occlusion, which was patent on 3D-DSA previously [Figure 1d and e]. In addition, diffusion-weighted imaging (DWI) revealed no apparent infarction at that time [Figure 1f].
Intraoperative photographs. (a) Intra-arterial embolus at M2-3 bifurcation (arrow: M2, arrowhead: M3) of the middle cerebral artery. (b) White color clot (arrow) was removed from the artery and blood flow spouted due to recanalization of occluded vessel. (c) Thrombus (arrow) at the distal M3 was also removed. (d) Anterior communicating artery complex and the aneurysm. (e) Clipping the aneurysm with straight clip. (f) Final view.
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F2
The M2 superior trunk was identified, and the M2-3 bifurcation was obstructed by an embolus [Figure 2a]. Arteriotomy was performed, and the embolus was removed [Figure 2b]. There was also an embolus at the distal M3, and it was removed in the same manner [Figure 2c]. The interhemispheric fissure was widely opened from the base, and the ACoA complex and the aneurysm were confirmed [Figure 2d]. A1s were temporarily blocked, and the aneurysm was detached from the surrounding structures. After confirming that there were no perforators, a straight clip was applied to the aneurysm and reinforced with a bayonet clip [Figure 2e and f].
Postoperative imaging. (a) Magnetic resonance angiography showed recanalization of the distal part of the middle cerebral artery. (b) Diffusion-weighted imaging showed a small infarction of the left frontal lobe and insula.
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F3
Postoperative MRA revealed recanalization of the occluded MCA and DWI demonstrated a small infarction of the left frontal lobe and insula [Figure 3].