Awake craniotomy for trapping a giant fusiform aneurysm of the middle cerebral artery

Background: Giant fusiform aneurysms of the distal middle cerebral artery (MCA) are rare lesions that, because of the absence of an aneurysm neck and the presence of calcified walls and partial thrombosis, can be difficult to clip without sacrificing the parent vessel. Moreover, when the aneurysm is located in the dominant hemisphere, it is not possible to test language and cognitive functions during surgical intervention, making the closure of the parent vessel extremely dangerous. Case description: A 46-year-old woman presented with a one-year history of frontal headache without neurological deficit. A magnetic resonance imaging and an angiography showed a giant fusiform aneurysm of the left M2 tract. Because of the location and the absence of a neck, the aneurysm was considered difficult to coil and not amenable to preoperative balloon occlusion; thus, the patient was a candidate for surgical treatment. After a preoperative psychological evaluation, patient underwent awake craniotomy with the asleep-awake-asleep technique. A standard left pterional approach was performed to expose the internal carotid artery, the MCA and the aneurysm originating from the frontal branch of the MCA. Neurological examination responses remained unchanged during temporary parent artery occlusion, and trapping was successfully performed. Conclusions: Awake craniotomy is a useful option in intracranial aneurysm surgery because it permits neurological testing before vessels are permanently clipped or sacrificed. With the asleep-awake-asleep technique, it is possible to perform a standard pterional craniotomy, which allows good exposure of the vascular structures without cerebral retraction.