Surgical treatment of a large fusiform distal anterior cerebral artery aneurysm with in situ end-to-side A3-A3 bypass graft and aneurysm trapping: Case report and review of the literature

BACKGROUND AND IMPORTANCE: Large fusiform aneurysms of the distal anterior cerebral territory are extremely rare and can be particularly challenging to treat. The circumferential pathology of fusiform lesions renders stand-alone clip or coil ablation unsatisfactory, and the deep, narrow corridor augments the difficulty of surgical approaches. In this setting, bypass procedures may be used to both treat the aneurysm definitively and preserve distal parent artery flow. We report a rare case of a large fusiform A3 aneurysm treated with trapping and concomitant end-to-side A3:A3 bypass. CLINICAL PRESENTATION: A 52-year-old man was evaluated after losing consciousness and experiencing a fall. A noncontrast computed tomography scan revealed a focal area of hemorrhage above the body of the corpus callosum, and computed tomography angiography showed a fusiform aneurysm of the right A3 artery. To treat the aneurysm definitively and preserve distal vessel flow, the patient was taken to surgery in anticipation of aneurysm ablation and cerebrovascular bypass. A large, fusiform right A3 aneurysm was identified. Intraoperative flow measurement demonstrated poor collateral circulation. The aneurysm was trapped with clips, and a right-to-left A3:A3 end-to-side in situ bypass was performed. Aneurysm occlusion and preserved distal vessel flow were confirmed with intraoperative angiography. CONCLUSION: Large fusiform aneurysms in the distal anterior cerebral artery region are rare, and the anatomy of these lesions and their vascular location render stand-alone surgical management technically challenging. End-to-side A3:A3 bypass combined with aneurysm trapping represents a feasible treatment strategy for lesions in this location.