Flow- and Caliber-Matched Dual Bypass for Fusiform Middle Cerebral Artery Bifurcation Aneurysm

Only 1 suitable STA branch was available, precluding a double-barrel STA strategy. The video details graft tailoring, temporary clipping, end-to-side anastomoses, and bypass sequencing. Intraoperative indocyanine green angiography and Doppler ultrasonography were used to confirm bypass patency and robust distal flow through both reconstructions (Figure 1). To preserve proximal perforators, distal trapping only was performed, allowing progressive aneurysm thrombosis while maintaining distal perfusion. Postoperative imaging demonstrated near-complete aneurysm thrombosis with preserved distal MCA flow (Figure 2). A flow-guided dual revascularization strategy can provide a reliable microsurgical solution for complex fusiform MCA bifurcation aneurysms involving both M2 trunks, emphasizing physiological donor selection and perforator-preserving aneurysm exclusion.