J Cerebrovasc Endovasc Neurosurg.  2021 Dec;23(4):359-364. 10.7461/jcen.2021.E2021.06.004.

Staged hybrid treatment for giant thrombosed fusiform aneurysm

• Noh Y
• Lee SH
• Yoon SM
• Song IH
• Oh JS

• KMID: 2523895
• DOI: http://doi.org/10.7461/jcen.2021.E2021.06.004

Abstract

Partially thrombosed intracranial aneurysm was difficult to treat because of higher recurrence rate compared to non-thrombosed saccular aneurysm. The author reports a case of partially thrombosed intracranial aneurysm causing transient ischemic symptom. A 40-year-old man presented with transient right hemiparesis. Brain magnetic resonance imaging (MRI) depicted low-signal intensity target-like mass lesion on left sylvian fissure, and magnetic resonance angiography (MRA) showed aneurysm on left middle cerebral artery bifurcation (MCBF), suggested thrombosed aneurysm. On operative finding, aneurysm wall had thick and atherosclerotic change, and it was fusiform aneurysm not saccular type. We initially planned direct clip for the aneurysm, but it was failed due to collapse of parent artery after clipping on aneurysm neck. To prevent ischemia, extracranial-intracranial bypass was performed and then thrombectomy with clip reconstruction. To remodeling the fusiform aneurysm, stent-assisted coiling was performed for remnant portion of aneurysm. With staged hybrid technique, giant thrombosed fusiform aneurysm was completely obliterated and the patient did not suffer any neurologic symptoms no longer.

Keyword

Thrombosis, Fusiform, Aneurysm

Figure

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  Fig. 1. (A) Initial magnetic resonance angiography (MRA) showed fusiform aneurysm of left middle cerebral artery bifurcation (MCBF). (B) T2-weighted axial image showed a 22×13 mm sized low signal intensity target-like lesion on left MCBF. (C) Gadolinium-enhanced brain vessel wall magnetic resonance imaging (MRI) showed enhancement of inner and outer layer of aneurysm.

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  Fig. 2. Digital subtraction angiography was performed and a 9.7×14.5 mm sized fusiform aneurysm was found on left middle cerebral artery bifurcation.

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  Fig. 3. After left frontotemporal craniotomy and sylvian dissection, left M1 segment of MCA, frontal and temporal branch of M2 segment, and giant aneurysm of left MCBF were exposed. (A) Schematic imaging of fusiform aneurysm of left MCBF. Direct clip was initially performed, but left M1 was also collapsed. (B) To prevent ischemia caused by long time of temporary clipping, anastomosis of parietal branch of STA and temporal branch of M2 was performed. (C) After temporary clipping of parent artery, thrombectomy was performed. Clip reconstruction with multiple permanent clip was performed, but proximal clip on aneurysm neck block the blood flow of parent artery. (D) Reposition of clip proximal to aneurysm neck was performed. (E) MEP of right extremities was recovered to baseline after clip reposition. MCA, middle cerebral artery; MCBF, middle cerebral artery bifurcation; STA, superficial temporal artery; MEP, motor evoked potential.

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  Fig. 4. Three months after aneurysm neck clip, follow up digital subtraction angiography was performed. (A) Aneurysm was slightly regrown, so stent-assisted coiling was performed. (B) Aneurysm was completely obliterated except for the neck of the aneurysm branching frontal branch of M2 segment of left middle cerebral artery.

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