Trapping Combined Double-bypass to Manage Unruptured Giant Thrombosed MCA Aneurysm

Management of giant complex thrombosed aneurysms of the middle cerebral artery (MCA) is challenging. Most giant MCA aneurysms possess some unfavorable features, such as incorporation of key MCA branches, efferent or perforating vessels originating from the sac, mural calcifications, intraluminal thrombi, or fusiform configurations. Due to these peculiar features, traditional clipping or simple endovascular coiling is generally not able to treat these aneurysms. Consequently, multiple revascularizations are needed for trapping the aneurysms. Here we used a simpler, low-flow double-bypass (frontal and parietal branch of superficial temporal artery-M4 MCA bypasses) over the high-flow saphenous vein or radial artery bypass grafts to manage unruptured giant thrombosed MCA aneurysm with preexisting ischemic injury.