A 32-year-old man was admitted to the emergency room with a history of sudden headaches, vomiting, and drowsiness. His past medical history showed arterial hypertension. On neurological examination, he was confused without localized neurological deficits. A computerized tomography (CT) scan showed a dense subarachnoid hemorrhage (SAH) with blood in the fourth ventricle. He underwent a digital angiography, which revealed a 6 mm fusiform SCA aneurysm without other signs of vascular dissection [].\nThe patient underwent surgery on the 15th post-hemorrhage day. He was positioned in park bench. A lumbar catheter was inserted and the cerebrospinal fluid (CSF) was drained to induce brain relaxation. A right subtemporal approach was performed, starting with a straight incision over the parietal branch of the STA. This artery was then dissected 10 cm from subcutaneous tissue under microscopic assistance. The temporal muscle was incised and a basal temporal craniotomy was performed. At that time, the lumbar drain was opened and 20 ml of CSF was drained. After a gentle lifting of the temporal lobe, the perimesencephalic cisterns were visualized and opened widely. The cerebellar tent was then incised. A fusiform dilatation of the SCA was observed between the anterior and lateral mesencephalopontine segments. The perforator arteries to brainstem were visualized proximal and distal to the aneurysm. A segment of the artery distal to the aneurysm that did not have perforator arteries was identified as the location for the anastomosis. The STA was then prepared for a terminolateral anastomosis. Temporary clips were positioned in the SCA segment and this artery was then opened and cleaned with heparin solution. Anastomosis was then performed in 40 min with 10-0 nylon single stitches. At the end of the procedure, the temporary clips were opened in a sequential manner. The patency of the anastomosis was confirmed by a micro-Doppler probe. Finally, aneurysm trapping was performed.\nThe patient had an unremarkable recovery and was discharged on postoperative day 7, with a prescription for 100 mg aspirin daily. The postoperative angiogram showed the patency of the bypass, with an excellent filling of the distal SCA segments from the bypass and total aneurysm exclusion [].
A 70-year-old woman with hypertension, hyperlipidemia, and a history of smoking presented with a peripheral fusiform SCA aneurysm found incidentally during a routine MRI investigation due to “black out” symptoms. The aneurysm was located 2 cm from the SCA origin, and measured 7 mm in maximal diameter [Figure and ]. After a thorough discussion of treatment options, the patient elected to undergo a combined subtemporal, presigmoidal approach. On the lateral aspect of the brainstem, the aneurysm was exposed along with the parent artery and two major efferent branches. One of these branches, the largest one, was superiorly directed and a double, smaller branch, presented inferiorly around the aneurysm fundus. It was necessary during microsurgical dissection to detach the aneurysm dome from the tentorial undersurface as well as from the 4th cranial nerve. Multiple clips were used to reconstruct the aneurysm without intra-operative complication. Intra-operative angiogram confirmed reconstruction of the fusiform aneurysm with preservation of distal flow [Figure –]. The patient tolerated the procedure well and was extubated and returned to the intensive care unit in stable condition. She was discharged home on the fourth post-operative day without new deficit.