Dome Resection and End-to-end Re-anastomosis for a Middle Cerebral Artery Fusiform Aneurysm of The M1 Segment: 2-Dimensional Operative Video.

Fusiform aneurysms of the middle cerebral artery (MCA) are both relatively uncommon, and challenging to treat given their pathophysiology, morphology, and anatomy (e.g. perforating arteries involvement).1,2 Endovascular treatment of fusiform MCA aneurysms can achieve good outcomes in well selected cases.3,4 Open microsurgical strategies are very effective in a case of fusiform MCA aneurysms with complex anatomy or perforator involvement.2,5,6 We demonstrate the bypass strategy for resection of a fusiform M1 MCA aneurysm.. A 48-year-old female was referred for the treatment of a growing incidental right M1 MCA fusiform aneurysm. Imaging showed a very tortuous M1 segment with no apparent perforator involvement, which we considered a candidate for resection and re-anastomosis. A modified mini-pterional transsylvian approach was performed as described before.7,8 A double STA-MCA bypass was performed to maintain flow to MCA territory and distal perforators in anticipation for a long temporary flow arrest due to complex aneurysmal dissection and re-anastomosis and also serve as a long term protective insurance. Resection and end-to-end re-anastomosis will preserve the antegrade flow and prevents the risk stump thrombosis carried by a simple trapping.9,10 In this video, we cover the nuances of this technique, including key steps to an efficient aneurysmal resection and complication avoidance. The patient tolerated the procedure well and post-operative imaging showed no aneurysmal remnant and flow restoration with no evidence of stroke. We discharged the patient home with a modified Rankin scale (mRS) of 0. The patient consented to the procedure and publication of his/her image.