Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies
A 56-year-old man presented with a headache and aphasia for 3 h. A CT scan in a local hospital showed a giant lesion in the left frontal lobe. After the lesion had been diagnosed as a giant unruptured and thrombotic MCA aneurysm, it was partially coiled. The patient was transferred to our department. The Digital Subtraction Angiography (DSA) revealed a giant serpentine aneurysm originating from the M1 segment, and direct clipping or further endovascular treatment was impossible. Furthermore, it would have been unavoidable to sacrifice the lenticulostriate perforators if we had trapped the aneurysm. Therefore, a left STA-RA-M3 bypass followed by a staged left cervical ICA occlusion was performed; the ICA was finally occluded after 7 days. The postoperative DSA demonstrated that the aneurysm was completely obliterated; the ICA was sacrificed, and the MCA territory was supplied by a bypass graft from STA. The patient did not present with any neurological deficits at the 3-month and 2-year follow-up appointments.