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A 48-year-old man hospitalized for subarachnoid hemorrhage harbored a ruptured aneurysm arising from an anomalous hyperplastic anterior choroidal artery. Endovascular treatment was performed and the aneurysm was successfully embolized with neck remnant. The anterior choroidal artery is a very important artery supplying critical brain structures in the treatment of intracranial vascular disease. Anomalous hyperplastic anterior choroidal artery is rare, so the embryological perspective is important for its recognition in surgical procedures.

Giant intracranial aneurysm is a life-threatening lesion and treatment of the aneurysm could be hazardous and complex. This study describes direct surgical treatment of giant middle cerebral artery (MCA) aneurysms using microvascular reconstruction techniques in 13 patients treated between 2006 and 2009. In all 13 patients, superficial temporal artery (STA)-MCA (M(2)) anastomosis was performed as a precaution prior to attacking the aneurysm. During surgery, microvascular reconstruction of incorporative arteries was additionally performed if the aneurysm was removed. Direct neck clipping was performed in four patients, trapping and removal of the aneurysm in one, and removal of the aneurysm with vascular reconstruction of the MCA in eight patients. Minor ischemic complications due to perforator ischemia were recognized in 6 patients, and 10 patients achieved functionally favorable outcomes (modified Rankin scale score 0 or 1). In direct surgery for giant MCA aneurysm, precautionary STA-M(2) bypass could provide appropriate surgical strategies tailored to individual cases, including direct clipping and removal of the aneurysm with or without vascular reconstruction. Microvascular reconstruction techniques are essential for complete cure of giant MCA aneurysms.

Background and Importance: A nonbifurcating cervical carotid artery is an extremely rare type of carotid artery anomaly. We present a patient with a nonbifurcating cervical carotid artery and a large aneurysm of the cavernous internal carotid artery (ICA). The patient was successfully treated with combined microsurgical and endovascular techniques. We describe this case with reference to the relevant literature., Clinical Presentation: A 66-year-old woman with progressive left external ocular movement dysfunction was found to have a large left cavernous ICA aneurysm. Serial magnetic resonance angiography revealed progressive growth of the lesion. In addition, conventional angiography showed a nonbifurcating cervical carotid artery and a persistent primitive trigeminal artery. The aneurysm was found unsuitable for direct surgery because of its size and location and for endovascular intervention because of extreme tortuosity of both carotid and right vertebral arteries. Surgery was performed in 2 stages. First, we performed an extracranial-intracranial high-flow bypass using radial artery graft, followed by proximal occlusion of the carotid artery. As the second stage, the patient underwent intravascular parent artery occlusion via the radial artery graft bypass to approach the intracranial carotid artery. The carotid artery was successfully coil embolized, and the aneurysm was undetectable on a postprocedure angiogram. Serial follow-up magnetic resonance imaging revealed thrombosis of the aneurysm., Conclusion: We report a rare case that involves the novel use of the radial artery graft bypass as an approach for parent vessel occlusion.