{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T22:31:22Z","timestamp":1769725882730,"version":"3.49.0"},"reference-count":28,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"19","license":[{"start":{"date-parts":[[2025,11,10]],"date-time":"2025-11-10T00:00:00Z","timestamp":1762732800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2025,11,10]]},"abstract":"\n BACKGROUND<\/jats:title>\n Fusiform middle cerebral artery (MCA) bifurcation aneurysms can be challenging to treat, and high-flow bypass with proximal\/distal parent vessel clipping may be an effective treatment option. Intraoperative ultrasound (ioUS)\u2013contrast-enhanced ultrasound (CEUS) may offer real-time critical insights regarding the perisaccular\/intrasaccular flow dynamic, to guide the intraoperative decision-making regarding different possibilities of trapping.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n A 65-year-old man with fibromuscular dysplasia, previously treated in 2012 for a right giant fusiform MCA prebifurcation aneurysm via superficial temporal artery\u2013MCA bypass\/clipping, presented with left upper limb paresthesia and confusion. Neuroradiological workup revealed a recurrence of the aneurysm distal to the previous clips, involving an M2 branch, with a dysplastic M1-M2 appearance and previous bypass failure. A high-flow external carotid (EC)\u2013internal carotid (IC) bypass with aneurysm trapping was planned. Multiple ioUS scans showed a significant reduction in intra-aneurysmal flow after EC-IC bypass, progressing to flow cessation and initial thrombosis after distal clipping alone, eliminating the need for proximal dissection and reducing intraoperative morbidity.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n The ioUS-CEUS confirmation of the changes in aneurysm flow after the bypass and of the rapid intraoperative aneurysm thrombosis that could be observed after distal clipping underscores the pivotal role that ioUS may have in intraoperative decision-making in complex vascular cases.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE25107<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case25107","type":"journal-article","created":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T11:12:01Z","timestamp":1769685121000},"source":"Crossref","is-referenced-by-count":0,"title":["Angiosonography-guided bypass with parent vessel occlusion for the treatment of a complex fusiform MCA aneurysm: illustrative case"],"prefix":"10.3171","volume":"10","author":[{"given":"Paolo","family":"Ferroli","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3789-957X","authenticated-orcid":true,"given":"Francesco","family":"Restelli","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Riccardo","family":"Ciocca","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Leonardo","family":"Maresca","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marco","family":"Demasi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matteo","family":"Palermo","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marco","family":"Schiariti","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Morgan","family":"Broggi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mario","family":"Stanziano","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6716-2923","authenticated-orcid":true,"given":"Elisa","family":"Ciceri","sequence":"additional","affiliation":[{"name":"Neurointerventional Radiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-3070-3529","authenticated-orcid":true,"given":"Giuseppe","family":"Ganci","sequence":"additional","affiliation":[{"name":"Neurointerventional Radiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Biagia La","family":"Pira","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Francesco","family":"Prada","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"3","key":"bib1","series-title":"Neurosurgery","first-page":"428","article-title":"Extracranial-intracranial bypass and vessel occlusion for the treatment of unclippable giant middle cerebral artery aneurysms","volume":"72","author":"Kalani","year":"2013","unstructured":"Kalani MYSZabramski JMHu YCSpetzler RF.Extracranial-intracranial bypass and vessel occlusion for the treatment of unclippable giant middle cerebral artery aneurysms. Neurosurgery. 2013;72(3):428-435."},{"issue":"2","key":"bib2","series-title":"J Neurosurg","first-page":"398","article-title":"Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree","volume":"120","author":"Kivipelto","year":"2014","unstructured":"Kivipelto LNiemel\u00e4 MMeling TLehecka MLehto HHernesniemi J.Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree. J Neurosurg. 2014;120(2):398-408."},{"key":"bib3","series-title":"World Neurosurg","first-page":"e282","article-title":"Complete or partial parent artery sacrifice: effect of vessel-occlusion strategies on complete obliteration of complex aneurysms","volume":"147","author":"Wessels","year":"2021","unstructured":"Wessels LHecht NFaust KSchneider UCzabanka MVajkoczy P.Complete or partial parent artery sacrifice: effect of vessel-occlusion strategies on complete obliteration of complex aneurysms. World Neurosurg. 2021;147:e282-e292."},{"issue":"10","key":"bib4","series-title":"Brain Sci","first-page":"1339","article-title":"The role of bypass surgery for the management of complex intracranial aneurysms in the anterior circulation in the flow-diverter era: a single-center series","volume":"12","author":"Acerbi","year":"2022","unstructured":"Acerbi FMazzapicchi EFalco JThe role of bypass surgery for the management of complex intracranial aneurysms in the anterior circulation in the flow-diverter era: a single-center series. Brain Sci. 2022;12(10):1339."},{"key":"bib5","series-title":"World Neurosurg","first-page":"e186","article-title":"The application of FLOW 800 ICG videoangiography color maps for neurovascular surgery and intraoperative decision making","volume":"122","author":"Shah","year":"2019","unstructured":"Shah KJCohen-Gadol AA.The application of FLOW 800 ICG videoangiography color maps for neurovascular surgery and intraoperative decision making. World Neurosurg. 2019;122:e186-e197."},{"issue":"suppl 1","key":"bib6","series-title":"Oper Neurosurg","first-page":"65","article-title":"Microscope-integrated quantitative analysis of intraoperative indocyanine green fluorescence angiography for blood flow assessment: first experience in 30 patients","volume":"70","author":"Kamp","year":"2012","unstructured":"Kamp MASlotty PTurowski BMicroscope-integrated quantitative analysis of intraoperative indocyanine green fluorescence angiography for blood flow assessment: first experience in 30 patients. Oper Neurosurg. 2012;70(suppl 1):65-73."},{"key":"bib7","series-title":"World Neurosurg","first-page":"277","article-title":"Indocyanine green and contrast-enhanced ultrasound videoangiography: a synergistic approach for real-time verification of distal revascularization and aneurysm occlusion in a complex distal middle cerebral artery aneurysm","volume":"125","author":"Acerbi","year":"2019","unstructured":"Acerbi FPrada FVetrano IGIndocyanine green and contrast-enhanced ultrasound videoangiography: a synergistic approach for real-time verification of distal revascularization and aneurysm occlusion in a complex distal middle cerebral artery aneurysm. World Neurosurg. 2019;125:277-284."},{"issue":"6","key":"bib8","series-title":"Acta Neurochir (Wien)","first-page":"1025","article-title":"Intraoperative cerebral angiosonography with ultrasound contrast agents: how I do it","volume":"157","author":"Prada","year":"2015","unstructured":"Prada FDel Bene MSaini MFerroli PDiMeco F.Intraoperative cerebral angiosonography with ultrasound contrast agents: how I do it. Acta Neurochir (Wien). 2015;157(6):1025-1029."},{"issue":"1","key":"bib9","series-title":"J Neurosurg","first-page":"49","article-title":"Giant intracranial aneurysms: natural history and 1-year case fatality after endovascular or surgical treatment","volume":"134","author":"Dengler","year":"2021","unstructured":"Dengler JR\u00fcfenacht DMeyer BGiant intracranial aneurysms: natural history and 1-year case fatality after endovascular or surgical treatment. J Neurosurg. 2021;134(1):49-57."},{"issue":"8","key":"bib10","series-title":"Acta Neurochir (Wien)","first-page":"1523","article-title":"Distal outflow occlusion with bypass revascularization: last resort measure in managing complex MCA and PICA aneurysms","volume":"158","author":"Esposito","year":"2016","unstructured":"Esposito GFierstra JRegli L.Distal outflow occlusion with bypass revascularization: last resort measure in managing complex MCA and PICA aneurysms. Acta Neurochir (Wien). 2016;158(8):1523-1531."},{"issue":"4","key":"bib11","series-title":"Neurosurgery","first-page":"670","article-title":"Bypass surgery for complex brain aneurysms: an assessment of intracranial-intracranial bypass","volume":"65","author":"Sanai","year":"2009","unstructured":"Sanai NZador ZLawton MT.Bypass surgery for complex brain aneurysms: an assessment of intracranial-intracranial bypass. Neurosurgery. 2009;65(4):670-683."},{"issue":"3","key":"bib12","series-title":"J Ultrasound","first-page":"243","article-title":"Fusion imaging for intra-operative ultrasound-based navigation in neurosurgery","volume":"17","author":"Prada","year":"2014","unstructured":"Prada FDel Bene MMattei LFusion imaging for intra-operative ultrasound-based navigation in neurosurgery. J Ultrasound. 2014;17(3):243-251."},{"issue":"1","key":"bib13","series-title":"Neurosurg Focus","first-page":"E6","article-title":"Dynamic assessment of venous anatomy and function in neurosurgery with real-time intraoperative multimodal ultrasound: technical note","volume":"45","author":"Prada","year":"2018","unstructured":"Prada FDel Bene MMauri GDynamic assessment of venous anatomy and function in neurosurgery with real-time intraoperative multimodal ultrasound: technical note. Neurosurg Focus. 2018;45(1):E6."},{"issue":"1","key":"bib14","series-title":"Sci Rep","first-page":"11797","article-title":"Quantitative analysis of in-vivo microbubble distribution in the human brain","volume":"11","author":"Prada","year":"2021","unstructured":"Prada FGennari AGLinville IMQuantitative analysis of in-vivo microbubble distribution in the human brain. Sci Rep. 2021;11(1):11797."},{"issue":"3","key":"bib1","series-title":"Neurosurgery","first-page":"428","article-title":"Extracranial-intracranial bypass and vessel occlusion for the treatment of unclippable giant middle cerebral artery aneurysms","volume":"72","author":"Kalani","year":"2013","unstructured":"Kalani MYSZabramski JMHu YCSpetzler RF.Extracranial-intracranial bypass and vessel occlusion for the treatment of unclippable giant middle cerebral artery aneurysms. Neurosurgery. 2013;72(3):428-435."},{"issue":"2","key":"bib2","series-title":"J Neurosurg","first-page":"398","article-title":"Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree","volume":"120","author":"Kivipelto","year":"2014","unstructured":"Kivipelto LNiemel\u00e4 MMeling TLehecka MLehto HHernesniemi J.Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree. J Neurosurg. 2014;120(2):398-408."},{"key":"bib3","series-title":"World Neurosurg","first-page":"e282","article-title":"Complete or partial parent artery sacrifice: effect of vessel-occlusion strategies on complete obliteration of complex aneurysms","volume":"147","author":"Wessels","year":"2021","unstructured":"Wessels LHecht NFaust KSchneider UCzabanka MVajkoczy P.Complete or partial parent artery sacrifice: effect of vessel-occlusion strategies on complete obliteration of complex aneurysms. World Neurosurg. 2021;147:e282-e292."},{"issue":"10","key":"bib4","series-title":"Brain Sci","first-page":"1339","article-title":"The role of bypass surgery for the management of complex intracranial aneurysms in the anterior circulation in the flow-diverter era: a single-center series","volume":"12","author":"Acerbi","year":"2022","unstructured":"Acerbi FMazzapicchi EFalco JThe role of bypass surgery for the management of complex intracranial aneurysms in the anterior circulation in the flow-diverter era: a single-center series. Brain Sci. 2022;12(10):1339."},{"key":"bib5","series-title":"World Neurosurg","first-page":"e186","article-title":"The application of FLOW 800 ICG videoangiography color maps for neurovascular surgery and intraoperative decision making","volume":"122","author":"Shah","year":"2019","unstructured":"Shah KJCohen-Gadol AA.The application of FLOW 800 ICG videoangiography color maps for neurovascular surgery and intraoperative decision making. World Neurosurg. 2019;122:e186-e197."},{"issue":"suppl 1","key":"bib6","series-title":"Oper Neurosurg","first-page":"65","article-title":"Microscope-integrated quantitative analysis of intraoperative indocyanine green fluorescence angiography for blood flow assessment: first experience in 30 patients","volume":"70","author":"Kamp","year":"2012","unstructured":"Kamp MASlotty PTurowski BMicroscope-integrated quantitative analysis of intraoperative indocyanine green fluorescence angiography for blood flow assessment: first experience in 30 patients. Oper Neurosurg. 2012;70(suppl 1):65-73."},{"key":"bib7","series-title":"World Neurosurg","first-page":"277","article-title":"Indocyanine green and contrast-enhanced ultrasound videoangiography: a synergistic approach for real-time verification of distal revascularization and aneurysm occlusion in a complex distal middle cerebral artery aneurysm","volume":"125","author":"Acerbi","year":"2019","unstructured":"Acerbi FPrada FVetrano IGIndocyanine green and contrast-enhanced ultrasound videoangiography: a synergistic approach for real-time verification of distal revascularization and aneurysm occlusion in a complex distal middle cerebral artery aneurysm. World Neurosurg. 2019;125:277-284."},{"issue":"6","key":"bib8","series-title":"Acta Neurochir (Wien)","first-page":"1025","article-title":"Intraoperative cerebral angiosonography with ultrasound contrast agents: how I do it","volume":"157","author":"Prada","year":"2015","unstructured":"Prada FDel Bene MSaini MFerroli PDiMeco F.Intraoperative cerebral angiosonography with ultrasound contrast agents: how I do it. Acta Neurochir (Wien). 2015;157(6):1025-1029."},{"issue":"1","key":"bib9","series-title":"J Neurosurg","first-page":"49","article-title":"Giant intracranial aneurysms: natural history and 1-year case fatality after endovascular or surgical treatment","volume":"134","author":"Dengler","year":"2021","unstructured":"Dengler JR\u00fcfenacht DMeyer BGiant intracranial aneurysms: natural history and 1-year case fatality after endovascular or surgical treatment. J Neurosurg. 2021;134(1):49-57."},{"issue":"8","key":"bib10","series-title":"Acta Neurochir (Wien)","first-page":"1523","article-title":"Distal outflow occlusion with bypass revascularization: last resort measure in managing complex MCA and PICA aneurysms","volume":"158","author":"Esposito","year":"2016","unstructured":"Esposito GFierstra JRegli L.Distal outflow occlusion with bypass revascularization: last resort measure in managing complex MCA and PICA aneurysms. Acta Neurochir (Wien). 2016;158(8):1523-1531."},{"issue":"4","key":"bib11","series-title":"Neurosurgery","first-page":"670","article-title":"Bypass surgery for complex brain aneurysms: an assessment of intracranial-intracranial bypass","volume":"65","author":"Sanai","year":"2009","unstructured":"Sanai NZador ZLawton MT.Bypass surgery for complex brain aneurysms: an assessment of intracranial-intracranial bypass. Neurosurgery. 2009;65(4):670-683."},{"issue":"3","key":"bib12","series-title":"J Ultrasound","first-page":"243","article-title":"Fusion imaging for intra-operative ultrasound-based navigation in neurosurgery","volume":"17","author":"Prada","year":"2014","unstructured":"Prada FDel Bene MMattei LFusion imaging for intra-operative ultrasound-based navigation in neurosurgery. J Ultrasound. 2014;17(3):243-251."},{"issue":"1","key":"bib13","series-title":"Neurosurg Focus","first-page":"E6","article-title":"Dynamic assessment of venous anatomy and function in neurosurgery with real-time intraoperative multimodal ultrasound: technical note","volume":"45","author":"Prada","year":"2018","unstructured":"Prada FDel Bene MMauri GDynamic assessment of venous anatomy and function in neurosurgery with real-time intraoperative multimodal ultrasound: technical note. Neurosurg Focus. 2018;45(1):E6."},{"issue":"1","key":"bib14","series-title":"Sci Rep","first-page":"11797","article-title":"Quantitative analysis of in-vivo microbubble distribution in the human brain","volume":"11","author":"Prada","year":"2021","unstructured":"Prada FGennari AGLinville IMQuantitative analysis of in-vivo microbubble distribution in the human brain. 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