PMC4418101_01
(a,b,c) The CT and CTA carried out at admission showed a right giant unruptured MCA aneurysm
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F1
The cerebral computed tomography (CT) and the computed tomographic angiogram (CTA) scans, carried out at admission, showed a right giant MCA aneurysm without subarachnoid hemorrhage (SAH) but with mass effect [Figure 1].
(a,b) The baseline cerebral angiography showed a giant right MCA aneurysm with the largest perpendicular diameters at the anteroposterior projection of about 20 x 30 mm. Note the delayed and reduced contrast opacification (a and b, black arrows) of the MCA distal to the aneurysm. (c) The slowing of the blood flow (c, black arrow) was well-evident in venous phase
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F2
The vascular flow through the MCA was very slow and its contrast opacification was delayed with respect to the ipsilateral anterior cerebral artery (ACA) by 1.75 s [Figure 2].
(a,b,c) The right carotid artery injection on the day of combined treatment just before surgery. It was clearly visible the flow diverter SILK stent (b, black arrow) allocated from the distal M1 to the proximal M2 for a length equal to 15 mm
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F3
At the end of the endovascular procedure, an angiogram was performed, which showed a major staunching of blood within the sac, patency of the MCA, and the correct position of both stents [Figure 3].
(a,b) The M2 inferior branch was sharply dissected from the wall of the giant aneurysm with a microblade, the vessel kept his steadiness facilitating the dissection and the branch of the MCA maintained the shape thanks to the Silk stent (b, black continued arrow) and the Enterprise stent (b, black interrupted arrow). (c) The dissection of the M2 superior branch with the exposure of adequate working-space around neck aneurysm for clipping. (d) Note the clipping of the aneurysm with three clips and patency of the protected neck
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Silk stent was visible through the transparency of the arterial wall. Stenting had made the vessel stiffer [Figure 4a and b], easing significantly surgical manipulation during the dissection and also preventing arterial spasms. After freeing the M2 superior trunk [Figure 4c], the aneurysmal neck has been exposed and multiple clips were applied. Three clips and the opening of the aneurysm were necessary to collapse the sac, which was then resected [Figure 4d].
(a,b) The CT performed 2 days after the combined treatment showed hypodensity in the surgical field
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F5
A postoperative CT showed hypodensity around the surgical field [Figure 5].
(a) The cerebral angiography performed 1 year after the combined treatment showed a normal blood flow through the M1 segment and both M2 trunks. (b) Note the allocation of the more proximal clip that runs along the wall of MCA being protected from stents
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F6