The application of high-resolution vessel wall imaging in the in situ bypass surgeries for complex anterior cerebral artery aneurysms

Objective: Complex anterior cerebral artery (ACA) aneurysms are still technically challenging to treat. Bypass surgery is needed to achieve aneurysm obliteration and ACA territory revascularization. Severe atherosclerosis of aneurysm walls can cause clip slippage, intraoperative rupture, postoperative ischemic events. How to assess the atherosclerotic changes in vascular walls by high-resolution vessel wall magnitude resonance imaging (VWI) is the key question in complex ACA aneurysm surgical management.Methods: This retrospective single-center study included eight patients diagnosed with complex anterior cerebral arteries admitted to our hospital for bypass surgery from January 2019 to April 2022. We discussed the appli-cation of VWI in aneurysms treated with in situ bypass and reviewed previous experience of revascularization strategies for complex ACA aneurysms.Results: In this study, we treated 8 cases of complex ACA aneurysms (3 communicating aneurysms/5 post -communicating aneurysms) over the prior one year. In situ side-to-side anastomosis (1 A2-to-A2/6 A3-to-A3) was performed in seven cases, and trapping combined with excision was performed in another case. Following bypass, complete trapping was performed in 4 cases, and proximal clipping was performed in 3 cases. No surgery-related neurological dysfunctions were observed. The final modified Rankin scale was 0 in seven of the eight cases and 2 in one case.Conclusion: High-resolution VWI, as a favorable preoperative assessment tool, provides insight into patient -specific anatomy and microsurgical options before operations, which can help neurosurgeons develop individ-ualized and valuable surgical plans.