Surgery for Middle Cerebral Artery Aneurysms with Unexpected Vascular Reconstruction

Abstract

Accumulating evidence of surgical treatment for intracranial aneurysms, the usual surgical clipping of aneurysm will progress as planned throughout the microsurgical procedure. However, emergent revascularization is occasionally required to repair accidentally injured vessels during the surgery. We present four cases of unexpected bypasses (troubleshooting) during microsurgical surgery for ruptured intracranial aneurysm at the middle cerebral artery. The first case was treated with superficial temporal artery (STA)—the inferior trunk of the middle cerebral artery (M2 inferior trunk) anastomosis—because of a tear on the M2 inferior trunk by inappropriate clipping procedure. The second and third cases were revascularizations of the branch artery firmly attached to the aneurysm dome with the anterior temporal artery (end-to-end anastomosis and transposition, respectively). The fourth case, a giant aneurysm, was finally treated with excision and end-to-end anastomosis after the first surgery, which was performed with STA-M2 inferior trunk anastomosis. In addition to extracranial-intracranial bypass, in situ bypass is the alternative intervention of cerebral vascular reconstruction, which does not require harvesting an extracranial donor artery, though it technically requires various types of anastomosis under an emergent situation.