{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:38:57Z","timestamp":1787027937398,"version":"build-2736575974"},"reference-count":38,"publisher":"MDPI AG","issue":"21","license":[{"start":{"date-parts":[[2025,10,23]],"date-time":"2025-10-23T00:00:00Z","timestamp":1761177600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background and Clinical Significance: Tandem pathology at the dominant-hemisphere middle cerebral artery (MCA)\u2014combining a wide-neck bifurcation aneurysm that shares the neck with both M2 origins and a short dorsal M1 fusiform dilation embedded in the lenticulostriate belt\u2014compresses the therapeutic margin and complicates device-first pathways. We aimed to describe an anatomy-led, microscope-only sequence designed to secure an immediate branch-definitive result at the fork and to remodel dorsal M1 without perforator compromise, and to place these decisions within a pragmatic perioperative framework. Case Presentation: A 37-year-old right-handed man with reproducible, load-sensitive cortical association and capsulostriate signs underwent high-fidelity digital subtraction angiography (DSA) with 3D rotational reconstructions. Through a left pterional approach, vein-respecting Sylvian dissection achieved gravity relaxation. Reconstruction proceeded in sequence: a fenestrated straight clip across the bifurcation neck with the superior M2 encircled to preserve both M2 ostia, followed by a short longitudinal clip parallel to M1 to reshape the fusiform segment while keeping each lenticulostriate mouth visible and free. Temporary occlusion windows were brief (bifurcation 2 min 30 s; M1 &lt; 2 min). No neuronavigation, intraoperative fluorescence, micro-Doppler, or intraoperative angiography was used. No perioperative antiplatelets or systemic anticoagulation were administered and venous thromboembolism prophylaxis followed institutional practice. The bifurcation dome collapsed immediately with round, mobile M2 orifices, and dorsal M1 regained near-cylindrical geometry with patent perforator ostia under direct inspection. Emergence was neurologically intact, headaches abated, and preoperative micro-asymmetries resolved without new deficits. The early course was uncomplicated. Non-contrast CT at three months showed structurally preserved dominant-hemisphere parenchyma without infarction or hemorrhage. Lumen confirmation was scheduled at 12 months. Conclusions: In dominant-hemisphere tandem MCA disease, staged, perforator-sparing clip reconstruction can restore physiologic branch and perforator behavior while avoiding prolonged antiplatelet exposure and device-related branch uncertainty. A future-facing pathway pairs subtle clinical latency metrics with high-fidelity angiography, reports outcomes in branch- and perforator-centric terms, and, where available, incorporates patient-specific hemodynamic simulation and noninvasive lumen surveillance to guide timing, technique, and follow-up.<\/jats:p>","DOI":"10.3390\/diagnostics15212678","type":"journal-article","created":{"date-parts":[[2025,10,24]],"date-time":"2025-10-24T01:35:11Z","timestamp":1761269711000},"page":"2678","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Perforator-Sparing Microsurgical Clipping of Tandem Dominant-Hemisphere Middle Cerebral Artery Aneurysms: Geometry-Guided Reconstruction of a Wide-Neck Bifurcation and Dorsal M1 Fusiform Lesion"],"prefix":"10.3390","volume":"15","author":[{"given":"Matei","family":"\u0218erban","sequence":"first","affiliation":[{"name":"Puls Med Association, 051885 Bucharest, Romania"},{"name":"Department of Neurosurgery, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Corneliu","family":"Toader","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R\u0103zvan-Adrian","family":"Covache-Busuioc","sequence":"additional","affiliation":[{"name":"Puls Med Association, 051885 Bucharest, Romania"},{"name":"Department of Neurosurgery, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Auricchio, A.M., Di Bonaventura, R., Marchese, E., Della Pepa, G.M., Sturiale, C.L., Menna, G., Skrap, B., Olivi, A., and Albanese, A. (2024). Navigating Complexity: A Comprehensive Approach to Middle Cerebral Artery Aneurysms. J. Clin. Med., 13.","DOI":"10.3390\/jcm13051286"},{"key":"ref_2","first-page":"e89365","article-title":"Modification of the Middle Cerebral Artery Bifurcation Angle Using a Stiff 0.014-Inch Microguidewire for Enhanced Woven EndoBridge Device Deployment","volume":"17","author":"Kuramoto","year":"2025","journal-title":"Cureus"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"107184","DOI":"10.1016\/j.vascn.2022.107184","article-title":"On the perspective of an aging population and its potential impact on drug attrition and pre-clinical cardiovascular safety assessment","volume":"117","author":"Fermini","year":"2022","journal-title":"J. Pharmacol. Toxicol. Methods"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Pesce, T., Keita, A., Agasse-Lafont, T., Sabia, M., Barbotin-Larrieu, F., Resiere, D., Puget, S., Drame, M., and Iosif, C. (2025). Real-World Data from the First Intracranial Aneurysm Cohort in the Eastern Caribbean from 2021 to 2024: The Population Characteristics, Treatment Outcomes, and Effectiveness of the Newly Established Regional Organization with Air Transfer to the First Tertiary Neurointerventional Center in the Eastern Caribbean. J. Clin. Med., 14.","DOI":"10.3390\/jcm14134565"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Feng, J., Tang, Y., You, W., Jiang, Y., Xu, Z., Zhao, Y., Liu, X., Lv, J., Liu, P., and Wei, H. (2024). Risk analysis of intracranial aneurysm rupture based on the arterial segment of origin. Front. Neurol., 15.","DOI":"10.3389\/fneur.2024.1339144"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Hellstern, V., Brenner, N., Cimpoca, A., Albina Palmarola, P., Henkes, E., Wendl, C., B\u00e4zner, H., Ganslandt, O., and Henkes, H. (2024). Flow diversion for unruptured MCA bifurcation aneurysms: Comparison of p64 classic, p64 MW HPC, and p48 MW HPC flow diverter stents. Front. Neurol., 15.","DOI":"10.3389\/fneur.2024.1415861"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1186\/s42155-020-00131-4","article-title":"The p48 MW flow modulation device for treatment of unruptured, saccular intracranial aneurysms: A single center experience from 77 consecutive aneurysms","volume":"3","author":"AlMatter","year":"2020","journal-title":"CVIR Endovasc."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Nawka, M.T., Zainal, I.A., Manceau, P.-F., Soize, S., and Pierot, L. (2025). Introducing the Caliber-Flow Status Scale (CFSS): A novel tool for assessing covered cortical branch status after flow diverter treatment of middle cerebral artery aneurysms. J. NeuroInterv. Surg.","DOI":"10.1136\/jnis-2024-022739"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"92","DOI":"10.5469\/neuroint.2024.00108","article-title":"Feasibility, Safety, and Efficacy of Endovascular vs. Surgical Treatment of Unruptured Multi-Sac Intracranial Aneurysms in a Single-Center Retrospective Series","volume":"19","author":"Goertz","year":"2024","journal-title":"Neurointervention"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Lo, Y.-L., Bih, Z.L., Yu, Y.-H., Li, M.-C., Chen, H.-M., and Wu, S.-Y. (2021). Long-Term Medical Resource Consumption between Surgical Clipping and Endovascular Coiling for Aneurysmal Subarachnoid Hemorrhage: A Propensity Score\u2013Matched, Nationwide, Population-Based Cohort Study. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18115989"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Park, J.H., Han, H.J., Kim, J.-J., Kim, Y.B., and Park, K.Y. (2025). Woven endobridge embolization versus microsurgical clipping for unruptured wide-neck cerebral aneurysms on middle cerebral artery bifurcation. BMC Neurol., 25.","DOI":"10.1186\/s12883-025-04199-0"},{"key":"ref_12","first-page":"2025-0046","article-title":"Reduced Radiation Exposure in Treating Wide-Neck Intracranial Bifurcation Aneurysms: Woven EndoBridge versus Stent-Assisted Coiling","volume":"19","author":"Abe","year":"2025","journal-title":"JNET J. Neuroendovasc. Ther."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"350","DOI":"10.4274\/dir.2022.211050","article-title":"Safety and efficacy of flow diverter stents in the treatment of middle cerebral artery aneurysms: A single-center experience and follow-up data","volume":"29","author":"Soydemir","year":"2023","journal-title":"Diagn. Interv. Radiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2024-0088","DOI":"10.5797\/jnet.cr.2024-0088","article-title":"A Case of Flow Diverter Placement for a Recurrent Large Thrombosed Middle Cerebral Artery Aneurysm","volume":"19","author":"Tanaka","year":"2025","journal-title":"J. Neuroendovasc. Ther."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e87","DOI":"10.1016\/j.wneu.2022.09.044","article-title":"Microsurgical Clipping of Middle Cerebral Artery Aneurysms: Complications and Risk Factors for Complications","volume":"168","author":"Metayer","year":"2022","journal-title":"World Neurosurg."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Al-Salihi, M.M., Al-Jebur, M.S., Abd Elazim, A., Saha, R., Saleh, A., Siddiq, F., and Ayyad, A. (2025). A Systematic Review and Meta-Analysis on the Safety of Antiplatelet Discontinuation Following Stent-Assisted Coil Embolization for Cerebral Aneurysms. NeuroSci, 6.","DOI":"10.3390\/neurosci6020034"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1136\/neurintsurg-2015-011682","article-title":"Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: A single-center series with special emphasis on covered cortical branches and perforating arteries","volume":"8","author":"Gawlitza","year":"2016","journal-title":"J. NeuroInterv. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Feng, X., Huang, J., Weng, S., Huang, C., Huang, M., Wen, Z., Ge, R., Li, C., Lin, J., and Yuan, H. (2025). Hemodynamic analysis of optimal branch selection for flow-diverting stents in middle cerebral artery bifurcation aneurysms: A pilot study. J. NeuroInterv. Surg.","DOI":"10.1136\/jnis-2025-023406"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Malvea, A., Miyake, S., Agid, R., Barazarte, H.A., Farb, R., Krings, T., Mosimann, P.J.R., Nicholson, P.J., Radovanovic, I., and Terbrugge, K. (2024). Clinical and Anatomical Characteristics of Perforator Aneurysms of the Posterior Cerebral Artery: A Single-Center Experience. Brain Sci., 14.","DOI":"10.3390\/brainsci14090934"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Xuexian, Z., Xuerou, M., Yuanjin, M., Bin, X., Wenqiu, P., Wei, Z., and Ruidong, W. (2025). Comparison of PED Flex and Lattice flow diverter in the treatment of unruptured intracranial aneurysms. Front. Neurol., 16.","DOI":"10.3389\/fneur.2025.1535044"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"110914","DOI":"10.1016\/j.jocn.2024.110914","article-title":"Development of a predictive grading system for postoperative ischemia following middle cerebral artery aneurysm clipping","volume":"130","author":"Lai","year":"2024","journal-title":"J. Clin. Neurosci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1007\/s00701-024-06150-7","article-title":"Improved rates of postoperative ischemia, completeness of aneurysm occlusion and neurological deficits in elective clipping of anterior circulation aneurysms over the past 20 years\u2014Association with technical improvements","volume":"166","author":"Siller","year":"2024","journal-title":"Acta Neurochir."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Meloni, A., Cau, R., Saba, L., Positano, V., De Gori, C., Occhipinti, M., Celi, S., Bossone, E., Bertacchi, J., and Punzo, B. (2024). Photon-Counting Computed Tomography Angiography of Carotid Arteries: A Topical Narrative Review with Case Examples. Diagnostics, 14.","DOI":"10.3390\/diagnostics14182012"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e6","DOI":"10.1136\/jnis-2024-022838","article-title":"Enhancing neurointerventional imaging: Use of ultra-high resolution photon counting detector CT in intracranial stent assessment","volume":"17","author":"Zeng","year":"2025","journal-title":"J. NeuroInterv. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"592","DOI":"10.3174\/ajnr.A8163","article-title":"Prasugrel Single Antiplatelet Therapy versus Aspirin and Clopidogrel Dual Antiplatelet Therapy for Flow Diverter Treatment for Cerebral Aneurysms: A Retrospective Multicenter Study","volume":"45","author":"Hohenstatt","year":"2024","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1136\/jnis-2024-021792","article-title":"Half-dose ticagrelor versus standard-dose clopidogrel in a dual antiplatelet regimen for stent-assisted coiling or flow diversion of unruptured intracranial aneurysms: A cohort study","volume":"17","author":"Li","year":"2024","journal-title":"J. NeuroInterv. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1149","DOI":"10.1007\/s10237-024-01829-3","article-title":"Treatment for middle cerebral artery bifurcation aneurysms: In silico comparison of the novel Contour device and conventional flow-diverters","volume":"23","author":"Lyu","year":"2024","journal-title":"Biomech. Model. Mechanobiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2547","DOI":"10.1007\/s00701-022-05184-z","article-title":"How do I: Venous reconstruction of accidentally injured superficial sylvian vein during the clipping of an unruptured cerebral aneurysm","volume":"164","author":"Segawa","year":"2022","journal-title":"Acta Neurochir."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"906","DOI":"10.1136\/neurintsurg-2019-015741","article-title":"Changes in mean arterial pressure and end-tidal carbon dioxide content affect venous sinus pressures in patients with idiopathic intracranial hypertension: A randomized study","volume":"12","author":"Tschoe","year":"2020","journal-title":"J. NeuroInterv. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e001290","DOI":"10.1136\/tsaco-2023-001290","article-title":"Crystalloid resuscitation is associated with decreased treatment delays and improved systolic blood pressures in a blood-constrained setting","volume":"9","author":"Yost","year":"2024","journal-title":"Trauma Surg. Acute Care Open"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1007\/s00381-022-05682-6","article-title":"The microanatomy of the Sylvian fissure","volume":"39","author":"Guner","year":"2023","journal-title":"Childs Nerv. Syst. ChNS Off. J. Int. Soc. Pediatr. Neurosurg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"101057","DOI":"10.1016\/j.jacadv.2024.101057","article-title":"Multiphysiologic State Computational Fluid Dynamics Modeling for Planning Fontan With Interrupted Inferior Vena Cava","volume":"3","author":"Hoganson","year":"2024","journal-title":"JACC Adv."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Hu, M., Chen, B., and Luo, Y. (2025). Computational fluid dynamics modelling of hemodynamics in aortic aneurysm and dissection: A review. Front. Bioeng. Biotechnol., 13.","DOI":"10.3389\/fbioe.2025.1556091"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"111834","DOI":"10.1016\/j.ejrad.2024.111834","article-title":"Diagnostic performance of Photon-counting CT angiography in peripheral artery disease compared to DSA as gold standard","volume":"182","author":"Ghibes","year":"2025","journal-title":"Eur. J. Radiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1007\/s00062-022-01207-5","article-title":"Trends of Expanding Indications of Woven EndoBridge Devices for the Treatment of Intracranial Aneurysms: A Systematic Review and Meta-analysis","volume":"33","author":"Lee","year":"2023","journal-title":"Clin. Neuroradiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"971","DOI":"10.3171\/2021.1.JNS202861","article-title":"Assessing the rate, natural history, and treatment trends of intracranial aneurysms in patients with intracranial dural arteriovenous fistulas: A Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) investigation","volume":"136","author":"Abecassis","year":"2022","journal-title":"J. Neurosurg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1950","DOI":"10.1007\/s10439-023-03214-0","article-title":"Considering the Influence of Coronary Motion on Artery-Specific Biomechanics Using Fluid\u2013Structure Interaction Simulation","volume":"51","author":"Fogell","year":"2023","journal-title":"Ann. Biomed. Eng."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"E21","DOI":"10.3171\/2019.5.FOCUS19234","article-title":"Flow induced inflammation mediated artery wall remodeling in the formation and progression of intracranial aneurysms","volume":"47","author":"Cebral","year":"2019","journal-title":"Neurosurg. 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