Surgical Management of a Giant Middle Cerebral Artery Aneurysm

Giant intracranial aneurysms (>25 mm) represent 5% of aneurysms¹ and have a poor natural history with high risk of rupture.² We describe a 74-year-old woman presenting with cognitive decline and dysphasia, initially having been referred to a memory clinic for a potential diagnosis of dementia. Magnetic resonance imaging demonstrated a left temporal lobe mass with surrounding edema, confirmed as a partially thrombosed giant middle cerebral artery aneurysm on catheter angiography. Awake balloon test occlusion was passed without deficit preoperatively. She then underwent craniotomy with opening of the aneurysm sac under temporary clipping and removal of the thrombus followed by clip reconstruction of the aneurysm neck. Postoperative magnetic resonance imaging demonstrated resolution of the edema and mass effect, and angiography confirmed aneurysm occlusion. Dysphasia and cognitive deficits resolved on postoperative psychometric testing. Written patient consent for surgical video publication and institutional approval was obtained (Video 1).