PMC7710454_01
(a) Computed tomography, at admission, demonstrating that localized thick clot in the left Sylvian fissure. Note that it comes with perifocal edema. (b) Preoperative cerebral angiography demonstrating that the left middle cerebral artery and anterior cerebral artery showed evidence of severe vasospasm. (c) Three-dimensional digital subtraction angiography, operative view, demonstrating that small aneurysm originates from the left sphenoidal segment of middle cerebral artery (M1) - insular segment of middle cerebral artery (M2) bifurcation (arrow). Note that severe vasospasm was observed in M1 (arrow head).
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F1
Computed tomography (CT) demonstrated a localized clot in the left Sylvian fissure with perifocal edema [Figure 1a]. CAG demonstrated severe vasospasm from the left sphenoidal segment of the middle cerebral artery (M1) to the insular segment of the middle cerebral artery (M2) and disclosed small aneurysm formation at the left M1-M2 bifurcation [Figure 1b and c].
(a) Intraoperative photograph during direct clipping demonstrating that the left M1-M2 bifurcation aneurysm was exposed. A fibrin cap covers the dome of the aneurysm and the source of intra-Sylvian hematoma was determined to be this small aneurysm. (b) The ruptured aneurysm was occluded with two clips. (c) After clipping of the aneurysm, spastic vessels were directly applied with nicardipine which was soaked in oxidized cellulose.
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F2
During surgery, after the ruptured aneurysm was clipped [Figure 2a and b], we removed as much thick clot around the vessels as possible and placed oxidized cellulose (Surgicel; Johnson & Johnson, Tokyo, Japan) around M1 and M2, which was soaked with 2 mg of an undiluted solution of nicardipine [Figure 2c].
(a) Postoperative cerebral angiography, performed just after the direct clipping of the left middle cerebral artery (MCA) aneurysm, demonstrating that the left M1 was completed dilated. (b) Magnetic resonance angiography (MRA), on the 3rd day of operation, demonstrating that the left MCA showed evidence of vasospasm. (c) MRA, on the 18th day of the operation, demonstrating no evidence of vasospasm on the left anterior cerebral artery and MCA.
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F3
CAG, performed immediately after the surgery, confirmed complete clipping and complete disappearance of angiographic vasospasm from M1 and M2, which were coated with nicardipine during surgery [Figure 3a]. Although her symptoms did not deteriorate after surgery, magnetic resonance angiography (MRA) performed 3 days after the operation showed reappearance of vasospasm [Figure 3b]. MRA at the discharge demonstrated disappearance of angiographical vasospasm [Figure 3c].