Neurosurgical Review

, Volume 39, Issue 4, pp 699–705 | Cite as

Tailored flow sequestration treatment using high-flow and low-flow bypass for partially thrombosed giant internal carotid artery aneurysm—a technical case report

  • Hirotaka HasegawaEmail author
  • Tomohiro Inoue
  • Akira Tamura
  • Isamu Saito
Case Report


Direct clipping of giant partially thrombosed intracranial internal carotid artery (ICA) aneurysms is challenging, especially when important perforating arteries are involved. Proximal occlusion with bypass represents a possible alternative approach. An 80-year-old female presented with worsening visual acuity and severe headache caused by partially thrombosed giant (38 mm in diameter) aneurysms of the right ICA, suggestive of impending rupture. Direct clipping in conjunction with temporary occlusion of the lesion involving the anterior choroidal artery (AChA) was considered too risky. Thus, we sequestrated the ipsilateral ICA flow into a low-flow and a high-flow system using two external carotid artery (ECA)-ICA bypasses and one in situ bypass with cervical ICA ligation. As a result, the low-flow system by the superficial temporal artery-middle cerebral artery (MCA) bypass perfused mainly the proximal MCA lesions and aneurysm, whereas the high-flow system by ECA-radial artery-M2 bypass exclusively supplied the residual distal MCA area. This tailored flow sequestration successfully interrupted intra-aneurysmal flow and accelerated near-complete thrombosis of the aneurysm while preserving the AChA and avoiding any significant neurological deterioration. We conclude that this method is effective for the management of giant partially thrombosed aneurysms of the ICA, especially when direct clipping is difficult.


Extracranial-intracranial arterial bypass Flow sequestration Giant intracranial aneurysm In situ arterial bypass Radial artery graft 




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Funding information


Supplementary material


Supplemental Video. Video demonstrates ECA-RA-M2 bypass and STA-MCA bypass with M3-M3 side-to-side bypass. With occlusion of the PCoA, ICA and proximal M2, tailored flow sequestration was completed. (MP4 20905 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Hirotaka Hasegawa
    • 1
    Email author
  • Tomohiro Inoue
    • 1
  • Akira Tamura
    • 1
  • Isamu Saito
    • 1
  1. 1.Department of NeurosurgeryFuji Brain Institute and HospitalFujinomiya-shiJapan

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