case_images: PMC11301812_01
case_images: (a) Preoperative non-contrast coronal head computed tomography (CT) demonstrates right holohemispheric acute subdural hematoma and subarachnoid hemorrhage with midline shift. (b) Preoperative coronal CT angiography demonstrates a 4 mm distal right middle cerebral artery pseudoaneurysm adjacent to the subdural hematoma.
case_images: SNI-15-247-g001.jpg
case_images: PMC11301812_01_SNI-15-247-g001.jpg
case_images: F1
case_images: Computed tomography (CT) of the head demonstrated an acute 18 mm right subdural hematoma (SDH) with subarachnoid hemorrhage (SAH), causing an 8 mm midline shift [Figure 1]. Preoperative CT angiography (CTA) of the head showed a 4 mm distal right MCA pseudoaneurysm adjacent to the SDH [Figure 1].
case_images: Intraoperative images showing (a) a platelet plug (arrow) disrupting the arachnoid membrane corresponding to the pseudoaneurysm, (b) The disrupted middle cerebral artery with a platelet plug (arrow) after removal of the overlying arachnoid. (c) The pseudoaneurysm (arrow) was resected to a clean edge proximally and distally. (d) Demonstration of good patency throughout the anastomosis after administration of indocyanine green dye.
case_images: SNI-15-247-g002.jpg
case_images: PMC11301812_01_SNI-15-247-g002.jpg
case_images: F2
case_images: Removal of the hematoma exposed an area of platelet plug overlying the pseudoaneurysm that had disrupted the arachnoid membrane [Figure 2]. There was a clear disruption of the vessel wall with no aneurysmal dilation to suggest a preexisting aneurysm [Figure 2]. Temporary clips were placed proximal and distal to the pseudoaneurysm, and the area of vessel injury was resected to a clean edge [Figure 2]. Administration of indocyanine green dye confirmed good patency of the anastomosis [Figure 2].
case_images: Postoperative coronal computed tomography (CT) and CT angiography show (a) improvement in both midline shift and subdural hematoma and (b) resection of pseudoaneurysm with patent distal middle cerebral artery.
case_images: SNI-15-247-g003.jpg
case_images: PMC11301812_01_SNI-15-247-g003.jpg
case_images: F3
case_images: Immediate postoperative head CT showed improvement in midline shift and previously noted SDH, as well as patency of the involved MCA branch [Figure 3].