Aneurysmoraphy or bypass? Surgical strategy for large M1 bifurcation aneurysm involving two branches based on vessel wall high-resolution MRI and intraoperative angiography.

Abstract

Middle cerebral artery (MCA) M1 bifurcation aneurysms are common because of hemodynamic. For regular-shaped and small aneurysms, direct clipping is optimal. Aneurysmoraphy or bypass blood flow reconstruction are most commonly used in large aneurysm clipping. Based on preoperative vessel wall high-resolution magnetic resonance imaging (VW-HRMRI) and intraoperative angiography, an appropriate surgery strategy could be decided. We report a case of large MCA M1 bifurcation aneurysm aneurysmoraphy according to preoperative VW-HRMRI. Intraoperative digital subtraction angiography (DSA) showed an aneurysm neck remnant, and we adjusted clips according to intraoperative DSA. This patient recovered well with a modified Rankin scale of 0 at discharge. This case demonstrates that preoperative VWHRMRI could supply more aneurysm characteristics for direct aneurysmoraphy. Intraoperative DSA effectively reduces the possibility of aneurysm remnant.