Bypass to the intracranial giant or large internal carotid artery aneurysms: superficial temporal artery to middle cerebral artery bypass re-visited.

OBJECTIVE Hunterian ligation of the internal carotid artery is an acceptable treatment modality for inoperable intracranial carotid aneurysms. Despite the risk of thrombo-embolic complications, ligation together with superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery is vital in some patients. Our aim is to present our experience in five patients in whom STA-MCA bypass and balloon occlusion were performed due to inoperable intracranial carotid artery aneurysms. METHODS During the last five years, five patients with inoperable internal carotid artery (ICA) aneurysms were treated by STA-MCA bypass surgery followed by permanent endovascular ICA occlusion. Patients were selected for bypass surgery on the basis of failing balloon test occlusion. Patients were managed in the intensive care unit after surgical and endovascular procedures. RESULTS Clinical improvement was noted in all patients and no major complication during the follow-up was seen. Aneurysmal thrombosis was confirmed in all patients. CONCLUSION Hunterian ligation associated with bypass surgery is an effective treatment method in selected patients. The following points should be considered for a good outcome: (1) experienced surgeon for bypass surgery, (2) experienced neuroradiologist for endovascular occlusion of the parent vessel as close to the aneurysm neck as possible, and (3) judicious postoperative management by means of anticoagulation, fluid replacement, and pressure control.