An Alternative Surgical Treatment of Giant Serpentine Aneurysm of the Middle Cerebral Artery: Resection and End-to-End Anastomosis.

Some giant intracranial aneurysms can develop serpentine morphology, secondary to a peculiar near-complete intra-aneurysmal thrombosis. The resulting complex angioarchitecture, along with atypical clinical presentations (i.e., mass effect, distal ischemia) seen, makes management of such aneurysms technically challenging. These aneurysms are not amenable to endovascular treatment, and hence the only remaining treatment option is a tailored microsurgical procedure (clipping/parent vessel occlusion or reconstruction/trapping/aneurysmorrhaphy) accompanied by a safety bypass (high-flow, low-flow, or in situ bypass, subject to dependence of distal circulation on proximal trunk with reference to aneurysm). The microsurgical procedure can be performed either in 1 or 2 stages (bypass followed by aneurysm treatment at a later date). Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass followed by aneurysm trapping/decompression is the most routinely performed microsurgical procedure for such aneurysms. The operative video illustrates an alternative surgical treatment of a giant serpentine aneurysm of the MCA: resection and end-to-end anastomosis. A 20-year-old man underwent microsurgery for a giant right MCA serpentine aneurysm. In view of the poor distal flow in the ipsilateral MCA territory, an STA-MCA bypass with aneurysm trapping/decompression was planned. Intraoperatively, the presence of a stretched and elongated ipsilateral MCA (secondary to aneurysm mass effect) plus the relatively narrow neck of the thrombosed aneurysm provided a rare opportunity to perform resection and end-to-end anastomosis (Video 1). Intraoperative and postoperative angiography confirmed the anastomosis patency. The patient's recovery was uneventful. This treatment can save operating time, eliminate donor artery-related morbidity, and offer a surgical alternative to the conventional strategy of STA-MCA bypass.