A case of spontaneous fusiform aneurysm in a middle cerebral artery branch which causes rapidly thrombosed formation in a short period

A 61-year-old man presented with the complaint of headache. Investigations revealed a fusiform middle cerebral artery aneurysm at the M2 part. The formation of the aneurysm rapidly developed to a partially thrombosed aneurysm in the course of four months. As regards the treatment of the aneurysm, at first we tried surgery with a superficial temporal artery middle cerebral artery bypass (STA-MCA bypass) and trapping of the aneurysm. However, during the procedure, it was difficult to control bleeding from the temporal muscle, bone flap, and subdural space. Because of this, we finished the STA-MCA bypass without trapping of the aneurysm and then, four days later, we confirmed bypass patency and treated the aneurysm using endovascular coil embolization. Based on both surgical and interventional investigations in this case and a review of the reported literature, the authors propose that there are two mechanisms causing the middle cerebral artery fusiform aneurysm to develop thrombosed formation rapidly: (i) Peripheral middle cerebral artery branches demand less blood flow than other major trunk arteries. (ii) Bypass flow maintains perfusion to the distal branches. On the other hand, this flow alteration caused by surgical vascular bypass may promote the development of the aneurysm to thrombosed formation. The treatment of a fusiform middle cerebral artery aneurysm at the M2 part is also discussed.