PMC8053432_01
Initial radiological findings. Magnetic resonance angiography showed unruptured cerebral aneurysm in the right middle cerebral artery bifurcation (7 mm in diameter) (a). Cerebral angiography performed 1 week after the initial transient ischemic attack did not exhibit aneurysm growth (b).
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F1
Magnetic resonance imaging (MRI) showed an UCA originating from the MCA bifurcation (7 mm in diameter) without evidence of acute cerebral infarction [Figure 1a]. Cerebral angiography was performed 1 week after the initial TIA, wherein a saccular aneurysm including the superior trunk of the M2 branch was confirmed [Figure 1b].
Magnetic resonance image (MRI) findings immediately after the recurrent transient ischemic attack (TIA). MRA performed immediately after the recurrent TIA detected rapid enlargement of the unruptured cerebral aneurysm (a). MRI showing acute cerebral infarction in the area supplied by a proximal perforating artery (b and c). Fluid-attenuated inversion recovery image showing peripheral edema in insular cortex attached to an enlarged aneurysmal sac (d).
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F2
MRI showed no acute brain ischemia, but revealed that the aneurysm had expanded from 7 mm to 14 mm in diameter [Figure 2a]. Three days after admission, the left hemiparesis and dysarthria reappeared, and MRI showed acute cerebral infarction in the area supplied by the MCA perforating artery [Figure 2b and c]. In addition, parenchymal edema in the insular cortex surrounding the aneurysm was observed on a fluid-attenuated inversion recovery image [Figure 2d].
Computed tomography angiography (CTA) findings. Preoperative CTA showing an enlarged right middle cerebral artery aneurysm (arrowhead).
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F3
Computed tomography (CT) angiography clearly depicts rapid enlargement of the aneurysmal sac [Figure 3].
Surgical findings. Aneurysmal sac with bleb (*) and MCA trunks exposed through the pterional approach (a). Temporal clipping of MCA trunks performed, but intimal pressure remained high (b). Aneurysmal sac shrunk using the suction and decompression technique (c). Angioplastic clipping performed to avoid obstruction of the parent artery by multiple clips (d). Indocyanine green imaging (e). Endoscopy showed directly compressed perforating arteries (arrow) with an enlarged aneurysmal sac from behind the shrunk aneurysmal sac (f).
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F4
Post application of surgical clips, intraoperative endoscopy clearly showed an association between the aneurysmal sac and the perforating artery [Figure 4a-f].
Postoperative computed tomography angiography (CTA) finding. Postoperative CTA showed that the multiple clipping for the middle cerebral artery aneurysm were successfully performed without the M2 trunk obstruction and aneurysmal neck remnant.
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F5
Postoperatively, CT angiography showed no evidence of the M2 trunk obstruction and the aneurysmal neck remnant [Figure 5].