PMC10159310_01
Preoperative images. (a) MR diffusion weighted images at presentation demonstrated cerebral infarction at right basal ganglia and corona radiata. (b) T2 weighted image-vessel wall MR showed aneurysm with partial thrombosis (30.57 mm) and enhancement of superior aspect. (c) Digital subtracted angiography confirmed a large saccular aneurysm (14.9 x 26.1 mm) at the right middle cerebral artery. (d) After early bifurcation of middle cerebral artery, the aneurysm was originated from the frontal branch. Superior and inferior divisions of frontal branch are branching out from the aneurysm dome. (arrows) (inlet).
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F1
III and left central type facial palsy were observed. Initial brain computed tomography (CT) and magnetic resonance imaging (MRI) showed acute cerebral infarction on the right basal ganglia and coronal radiata [Figure 1a]. MRI showed a prominent wall enhancement at the superior aspect and partial thrombus in the aneurysm [Figure 1b]. Digital subtracted angiography confirmed a giant saccular aneurysm at the right MCA and there were two efferent arteries (superior and inferior divisions) from the inferolateral aspect of the aneurysm [Figures 1c and d].
Illustration of operation plan. Gray blade with blue spring represent aneurysm clips. Possible surgical options based on the preoperative images are as follows: (a) direct clipping if possible. (b) Neck clipping combined with anastomosis of superior division of the frontal branch-graft from superficial temporal artery (red bar). (c) Trapping of aneurysm combined with double-barrel bypass via two branches of superficial temporal arteries (red bars).
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F2
Several surgical options were consided based on preoperative images, to obliterate aneurysm and maintain distal flow simultaneously [Figure 2].
Operative pictures. (a) the aneurysm was originated from the frontal branch of the middle cerebral artery. Superior (solid arrow) and inferior (open arrow) divisions of frontal branch are branching out from the aneurysm. (b) Clipping of main sac was done using multiple fenestrated straight clips. And then the superior division of frontal branch and superior temporal artery's parietal branch were anastomosed in end-to-end fashion. (arrowheads).
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F3
Branches originating from the aneurysm were identified - superior devision of the frontal branch, inferior division of the frontal branch, and lenticulostriate arteries from the frontal branch [Figure 3].
Illustration of operation. Gray blade with blue spring represents fenestrated straight clips while gold blade with violet spring means temporary mini clips. (a) After early bifurcation of middle cerebral artery, the aneurysm was originated from the frontal branch. Superior and inferior divisions of frontal branch are branching out from the aneurysm. (b) Superior division of frontal branch was cut to enable clipping without compromising parent artery. (c) Clipping of main sac was done using multiple fenestrated straight clips. (d) Superior division of frontal branch and distal end of superior temporal artery's parietal branch (arrowheads, red bar) were anastomosed in end-to-end fashion.
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Inferior division of the frontal branch was preserved [Figure 4]. Subsequently, end-to-end anastomosis was done between a parietal branch of STA and a superior division of the frontal branch from an aneurysm, cut, and prepared in advance [Figure 4].
Postoperative images. (a) A digital subtracted angiography at postoperative day 3 showed no residual aneurysmal sac. (b) Patent flow was observed from a graft of superficial artery (arrowheads) to the frontal lobe and insula.
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F5
Digital subtracted angiography at postoperative day 3 showed no residual aneurysmal sac and good flow was observed from the donor - right STA parietal branch - to the recipient - M2 area [Figure 5].