PMC4828945_01
Initial native multislice computed tomography showing no obvious signs of cerebral ischemia
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F1
The initial head MSCT showed no obvious signs of cerebral ischemia [Figure 1].
(a) Native multislice computed tomography showing left-side fronto-opercular cerebral ischemia and subarachnoid hemorrhage. (b) Multislice computed tomography angiography showing an aneurysm on the left M2 middle cerebral artery branch 5 mm from the M1 middle cerebral artery branch bifurcation. Digital subtraction angiography, lateral (c) and anteroposterior (d) view showing an M2 branch bifurcation aneurysm, absence of blood flow in the "smaller" frontal opercular M3 segment implying thrombosis and filiform blood flow in the "larger" insular M3 segment resembling partial vessel thrombosis
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F2
By comparing the DSA and MSCT scans, it could be concluded that the fully thrombosed frontal M3 branch was the cause of the cerebral ischemia and that the second opercular M3 branch was in peril due to partial thrombosis [Figure 2].
(a) Intraoperative picture showing fusiform aneurysm on the M2 middle cerebral artery branch, encircled. Smaller upper M3 branch is marked with a yellow arrow and lower larger M3 middle cerebral artery branch is marked with a black arrow. A temporary clip has been placed on the M2 while aneurysm preparation is performed. (b) Intraoperative picture showing definite clip placement on the M2 middle cerebral artery branch for definite occlusion
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F3
Bearing in mind the clearly ischemic portion of the frontal operculum irrigated by the smaller upper M3 branch, as shown by DSA and micro-Doppler, as well as the fact that the whole circumference of the vessel wall was evidently changed into a fusiform aneurysm, the permanent solution was complete M2 occlusion by placing a clip proximally to the aneurysm [Figure 3].
Intraoperative picture showing: (a) Thrombus removal from the "larger" insular M3 middle cerebral artery branch after a small linear vessel incision, (b) backflow verification after thrombus removal
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F4
After the thrombus evacuation and verified backflow, we decided to protect this vessel by creating an STA-MCA bypass [Figure 4].
Intraoperative picture showing superficial temporal artery to M3 middle cerebral artery branch end-to-side anastomosis, encircled
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F5
The STA was prepared with a fish-mouth opening and sutured with 10-0 prolene to the recipient vessel by end-to-side anastomosis [Figure 5].
Intraoperative picture showing the final clip placed right before the anastomosis, encircled, thus creating aneurysm trapping
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F6
This bleeding was successfully stopped by placing another clip distal to the aneurysm and in front of the bypass on the lower larger M3 MCA branch, thus creating a definite aneurysm trapping [Figure 6].
Postoperative digital subtraction angiography and multislice computed tomography on the day of discharge, anastomosis is marked by arrow
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F7
On the second postoperative day, DSA showed a patent bypass [Figure 7].