PMC9941034_01
Preoperative scans. MRI axial (A) and sagittal views (B) show an aneurysm with partial thrombosis of 54 mm in diameter in the cavernous segment of the right ICA (arrows). The angiography images (C) and (D) confirmed the presence of the aneurysm with poor collateral circulation.. MRI: magnetic resonance imaging, ICA: internal carotid artery
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FIG1
An MRI study revealed a giant aneurysm in the cavernous portion of the right ICA (Figure 1).
Intraoperative images. (A) right pterional craniotomy; (B) the carotid bifurcation is identified, and the external carotid artery is isolated (arrow); (C) a termino-lateral anastomosis is made with a radial artery graft previously obtained from the left arm with an 8-0 suture. After completion of the anastomosis, the clamp is released (arrow), and patency of the proximal bypass is confirmed; (D) the recipient artery is prepared at the level of the Sylvian fissure. The inferior trunk of the MCA is selected for the second end-to-side anastomosis. The anastomosis is completed with a 9-0 suture using separate points (arrow); (E) the anastomosis is completed (arrow), and its functioning is verified with the intraoperative Doppler; (F) after closing the ICA at the bifurcation with a suture, a clip is positioned just proximal to the origin of the ophthalmic artery to trap the cavernous sinus aneurysm permanently (arrow).. MCA: middle cerebral artery; ICA: internal carotid artery
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FIG2
After that, an end-to-side anastomosis between the radial graft and the middle cerebral artery was performed using nylon 9-0 (Figure 2).
Postoperative images at two months (A-C) and six months (D-F) after surgery. Images (A) and (D) from the coronal view show a patent bypass (arrows). Images (B) and (E) show the CTA in axial view. The MCA's bypass (arrow) and branches are seen without evidence of low-density areas. Images (C) and (F) show pre- and postoperative (six months) images of the aneurysm. The mass effect is reduced with the improvement of the cavernous sinus symptomatology.. CTA: computed tomography angiography; MCA: middle cerebral artery
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FIG3
The postoperative course was uneventful, and the patient was discharged three days later to continue with a follow-up at the outpatient clinic (Figure 3).