Patient Information
A 62-year-old right-handed woman suffered from virus meningoencephalitis when she was 15 years old. Subsequently, she had 15 min night panic attacks with hallucinations, hemihypesthesia without seizures. This paroxysm stopped in 5 years with no treatment. In 2015 MR tomography, MR angiography showed right basal ganglion atrophy and 2 aneurysms of the right MCA. The patient underwent endovascular operation of M1 segment in 2015 at another medical center. Recently, she has had rare episodes of headache and depression; therefore, she received counseling with a psychotherapist and has taken carbamazepine 400 mg a day. She has no serious neurologic deficit.
Imaging studies
Computed tomography (CT) angiography and magnetic resonance imaging (MRI) conducted at our neurosurgical center revealed a big partial thrombosed fusiform M1 segment aneurysm of the right MCA (15 × 12.5 × 17.5 mm) and a small saccular aneurysm of the anterior temporal artery (5 × 4 × 4 mm), which was endovascularly occluded (Figs. 1 and 2).
Surgical findings
Preoperative diagnostic Matas test revealed a reversible weakness in the left arm and leg for 5 min, which confirmed the insufficient collateral blood flow ruling out the possibility of a destructive operation. For this reason, we decided to apply a bypass anastomosis and then perform endovascular occlusion of the MCA and aneurysm.
The operation was conducted in the hybrid operating room equipped with intraoperative angiography and flat panel CT-perfusion (Artis zeego, Siemens Healthineers, Forchheim, Germany). Firstly, a pterional craniotomy with resection of the zygomatic arch was performed to facilitate retraction of the temporalis muscle to the lower part. The internal maxillary artery (IMaxA) was exposed in the pterygopalatine fossa. The proximal IMaxA was then secured with a temporary clip, and the distal end divided with ligation. An end-to-end anastomosis was applied connecting the radial artery graft and the proximal segment of the MA. The distal end of the donor graft was then anastomosed with M2 segment of the right MCA. Within 2 postoperative days, there were no neurological complications. The CT angiography showed a good patency of the bypass (Fig. 3).
Postoperative course
After a 2-day observation, we executed the conventional МСА occlusion with a balloon tip catheter and assessment of neurological condition for 10 min (Fig. 4).
Meanwhile, the CT perfusion test with cerebral blood volume (CBV) assessment was conducted to reveal the possible ischemic damage to the brain [2] (Fig. 5). Over this time, no neurological complications were detected.
There was a good graft blood supply of the temporal, parietal, and frontal branches during the MCA occlusion, which was identified by the cerebral angiography. Finally, the proximal part of the aneurysm and the parent MCA artery were successfully occluded with platinum spiral coils (Figs. 6 and 7). The patient received 3000 units of heparin intravenously during endovascular procedures.
Postoperative MRI angiography revealed a total aneurysm occlusion and good filling of distal MCA branches maintained by the bypass (Fig. 8).
The patient recovered quickly without any neurological deterioration and was discharged home in good condition in 10 days.