ArticleJournal of neurosurgery. Case lessons2025
Angiosonography-guided bypass with parent vessel occlusion for the treatment of a complex fusiform MCA aneurysm: illustrative case.
Article in Journal of neurosurgery. Case lessons, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundFusiform middle cerebral artery (MCA) bifurcation aneurysms can be challenging to treat, and high-flow bypass with proximal/distal parent vessel clipping may be an effective treatment option. Intraoperative ultrasound (ioUS)-contrast-enhanced ultrasound (CEUS) may offer real-time critical insights regarding the perisaccular/intrasaccular flow dynamic, to guide the intraoperative decision-making regarding different possibilities of trapping. OBSERVATIONS: A 65-year-old man with fibromuscular dysplasia, previously treated in 2012 for a right giant fusiform MCA prebifurcation aneurysm via superficial temporal artery-MCA bypass/clipping, presented with left upper limb paresthesia and confusion. Neuroradiological workup revealed a recurrence of the aneurysm distal to the previous clips, involving an M2 branch, with a dysplastic M1-M2 appearance and previous bypass failure. A high-flow external carotid (EC)-internal carotid (IC) bypass with aneurysm trapping was planned. Multiple ioUS scans showed a significant reduction in intra-aneurysmal flow after EC-IC bypass, progressing to flow cessation and initial thrombosis after distal clipping alone, eliminating the need for proximal dissection and reducing intraoperative morbidity. LESSONS: The ioUS-CEUS confirmation of the changes in aneurysm flow after the bypass and of the rapid intraoperative aneurysm thrombosis that could be observed after distal clipping underscores the pivotal role that ioUS may have in intraoperative decision-making in complex vascular cases. https://thejns.org/doi/10.3171/CASE25107.
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