Frontotemporal Approach for Infectious Aneurysm Trapping and Superficial Temporal Artery-Middle Cerebral Artery Bypass.

Although neurotropic, the varicella-zoster virus (VZV) is a rare cause of mycotic cerebral aneurysms. As with other mycotic aneurysms, medical management can provide complete resolution. Surgery for refractory aneurysms can be complicated by vessel friability and complex morphologies requiring excision and revascularization. In Video 1, we present key steps in the surgical management of a previously ruptured and growing fusiform mycotic cerebral aneurysm. A 58-year-old woman with a history of neuromyelitis optica resulting in lower-extremity paraplegia and chronic immunosuppression presented elsewhere with a Hunt and Hess 2 and Fisher grade 3 subarachnoid and intraparenchymal hemorrhage. Initial angiography demonstrated a 3-mm right distal middle cerebral artery fusiform aneurysm. Because of a recent shingles episode and cerebrospinal fluid studies consistent with a viral cause (glucose 26, protein 166, lymphocytes 64%), acyclovir and steroid therapy was commenced. She was transferred to our institution after serial angiography demonstrated aneurysm growth to 7 mm over 1 week. On arrival, she was neurologically intact except for her baseline lower-extremity weakness. To address the lesion, she underwent a superficial temporal artery-to-middle cerebral artery direct bypass, followed by clip trapping and microsurgical excision of the diseased arterial segment. Pathologic analysis confirmed the presence of VZV in the aneurysm walls. Postoperatively, she was at her neurologic baseline and was discharged 2 weeks later. Immediate and 5-month postoperative vascular imaging demonstrated bypass patency and no residual aneurysm. Similar to other mycotic aneurysms, VZV-associated cerebral aneurysms refractory to medical management can be safely treated with definitive excision and revascularization in selected patients.