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Aneurysmal occlusion after blood flow revascularization is a promising management strategy for the treatment of intracranial giant aneurysms. However, it is necessary to design robust revascularization for preventing postoperative flow-related infarctions caused by abrupt occlusion of the parent vessels. Since direct anastomosis of donor vessels to recipient vessels near giant aneurysms is often difficult, it is preferable to select cortical recipient branches away from the aneurysm, thus providing a sufficient working space for the surgeon. In this paper, the authors' goal was to identify distal cortical recipient arteries on the brain surface, based on pulsed Doppler ultrasonography analysis of blood flow alteration after temporary closure of the efferent vessels. This method is used to visualize the area around the sacrificed vessels, omits intraoperative arteriography or the risk of a surgical trace of the vessels by dissecting the distal sulci, and could be advantageous for necessary and sufficient revascularization.

Preoperative balloon test occlusion (BTO) has generally been used to predict intraoperative tolerance for temporary vascular occlusion to prevent a premature rupture during aneurysm surgery or to perform complete treatment for large aneurysms. We encountered a case in which intraoperative motor evoked potential (MEP) revealed peculiar changes after temporal occlusion of the internal carotid artery during aneurysm surgery, in spite of showing sufficient tolerance to preoperative BTO. We emphasize the importance of intraoperative MEP monitoring, even if patients have shown tolerance in preoperative BTO.