Hybrid Treatment for a Giant Fusiform Partially Thrombosed Middle Cerebral Artery Aneurysm With Superficial Temporal Artery to Middle Cerebral Artery Bypass Followed by Endovascular Vessel Sacrifice: 2-Dimensional Operative Video

We present the case of a 62-year-old patient who presented with symptoms of difficulty in wordfinding and vertigo.Computed tomography scan of the head was performed, which showed an oval-shaped area of hyperdensity at the leftsuperior temporal lobe, measuring around 3.7 x 2.3 cm. MRI, axial T2 imaging revealed a giant, partially thrombosed,fusiform left middle cerebral artery (MCA) aneurysm. Further evaluation with digital subtraction angiography again revealed the filling portion of the fusiform aneurysm, involving the left temporal MCA division with visible stenosis of theparent vessel both before and after the fusiform segment, consistent with a dissecting aneurysm. The outflow branch of the aneurysm supplied the Wernicke area.Treatment options were discussed. Given the eloquence of the outflow vessel, a flow preservation option was necessary. The patient consented to the procedure. Direct superficial temporal artery to middle cerebral artery bypass was performed, and perfusion was maintained in eloquent regions. Under road map guidance, the aneurysmwas occluded using platinum coils. Fusiform aneurysmsof the middle cerebral artery MCA are uncommon and cancause compression or distal thrombus migration. In complex cases, surgical clipping or endovascular coiling maynot work, requiring vessel sacrifice and direct arterial bypass for effective treatment. A literature review was performed including 17 studies on cranial aneurysms treated with endovascular embolization and arterial bypass;the overall success rate was 84%, with 16% of patients experiencing postoperative infarction.(1-17)This video article and literature review provide valuable insights into the treatment of complex giant fusiform aneurysms with superficial temporal artery to middle cerebral artery bypass and endovascular vessel sacrifice.