Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies
A 19-year-old man suffered from a sudden severe headache and became unconsciousness 2 h before admission. A physical examination showed a Glasgow Coma Scale (GCS) score of 6, and the right pupil was dilated. A computed tomography (CT) scan revealed SAH and a large hematoma in the right temporal lobe. The emergent CT angiogram demonstrated a giant ruptured aneurysm originating from the M1 segment. Open surgery was conducted emergently. After evacuating the majority of the hematoma, the aneurysm was exposed. The lenticulostriate perforators from M1 were meticulously identified. After we confirmed that these perforators were not involved in the neck of the aneurysm, the aneurysm was clipped using a neck reconstruction technique. The patient recovered quickly after surgery, and the GOS score reached 5 at the 3-month follow-up appointment. A postoperative CT angiography (CTA) demonstrated complete obliteration of the aneurysm.\nThe recurrence of the aneurysm was detected by CTA at the 1-year appointment and confirmed at the 2-year follow-up appointment; it was determined that reoperation was required. Intraoperative findings showed a dissecting aneurysm with severe calcification of the aneurysmal wall, which prevented direct aneurysm clipping. Fortunately, the lenticulostriate perforators did not originate from the site of the aneurysm location. Therefore, the aneurysm was trapped after a superficial temporal artery (STA)–M3 bypass had been performed. The patient recovered without any neurological deficits. The postoperative CTA demonstrated complete obliteration of the aneurysm and patency of the bypass graft.