Flow Diversion of a Thrombosed Middle Cerebral Artery Bifurcation Aneurysm Presenting With Ischemic Stroke - A Case Report

Q: Why is ischemic stroke from MCA bifurcation aneurysms difficult to manage?

Because spontaneous intra-saccular thrombosis is extremely rare, clinicians must balance the risk of further thromboembolism against the danger of aneurysm rupture.

Q: What imaging supported the diagnosis in this case?

Computed tomography angiography suggested an atypical luminal contour, while vessel wall MRI supported intra-aneurysmal thrombosis and aneurysm instability, alongside interval change on serial conventional angiography.

Q: What treatment was used and what were the results?

Endovascular flow diversion was performed across the aneurysm into the superior division, with dual antiplatelet therapy initiated. The procedure was well tolerated and produced excellent angiographic results.

Sep 30, 2026

Uploaded by Jasmine

Middle cerebral artery (MCA) bifurcation aneurysms are usually incidental on imaging or present with subarachnoid hemorrhage and are commonly treated surgically because of peripheral location and complex anatomy. Ischemic stroke from spontaneous intra-saccular thrombosis is extremely uncommon and creates management tension between thromboembolism risk and aneurysm rupture risk. This case report describes a 68-year-old woman whose left MCA infarcts and imaging supported intra-aneurysmal thrombosis and instability. Endovascular flow diversion with dual antiplatelet therapy was well tolerated with excellent angiographic outcomes.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages8

Reading Time20 min

AccessFree to download

Abstract

Introduction

Case Presentation

Review began 11/25/2025 Review ended 12/03/2025 Published 12/08/2025 © Copyright 2025 Agwu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98718 Open Access Case Report Flow Diversion of a Thrombosed Middle Cerebral Artery Bifurcation Aneurysm Presenting With Ischemic Stroke: A Case Report Chibueze I. Agwu 1 , Rami Z. Morsi 2 , Archit B. Baskaran 2 , Michael C. Hurley 3 1. Pritzker School of Medicine, University of Chicago, Chicago, USA 2. Neurology, University of Chicago Medicine, Chicago, USA 3. Radiology, University of Chicago Medicine, Chicago, USA Corresponding author: Chibueze I. Agwu, [chibueze.agwu@uchospitals.edu](chibueze.agwu@uchospitals.edu) Abstract Middle cerebral artery (MCA) bifurcation aneurysms typically present incidentally on imaging or with subarachnoid hemorrhage and are often managed surgically due to their peripheral location and complex anatomy. Ischemic stroke due to spontaneous Intrasaccular thrombosis is extremely rare and poses a management dilemma due to the combined risk of further thromboembolism and aneurysm rupture. A 68-year-old woman with a history of smoking presented with symptoms of a left MCA syndrome with acute left MCA territory infarcts on magnetic resonance imaging (MRI) . Computed tomography angiography demonstrated a left MCA bifurcation aneurysm with an atypical luminal contour, which suggested intrasaccular thrombus. Vessel wall MRI supported the diagnosis of intrasaccular thrombus and aneurysm instability. In view of the risks of both recurrent thromboembolism and rupture, endovascular flow diversion was performed across the aneurysm into the superior division with initiation of dual antiplatelet therapy. The procedure was well tolerated and yielded excellent angiographic results. The management of partially thrombosed MCA aneurysms presenting with ischemic stroke remains challenging and is not well defined. Although flow diversion addressed both the thromboembolic and rupture risks in this case, it carries a significant risk of iatrogenic clot destabilization. Broader data collection through multicenter registries may help clarify the natural history and optimal management of this rare presentation. Categories: Radiology, Neurosurgery Keywords: bifurcation aneurysm, clot destabilization, flow diversion, interventional neurosurgery, thrombosed middle cerebral artery Introduction Middle cerebral artery (MCA) bifurcation aneurysms account for 18-36% of all intracranial aneurysms [1] . Large series estimate an overall annual rupture risk of approximately 0.36%, with small incidental aneurysms (e.g., <7 mm anterior circulation aneurysms, including MCA bifurcation, in the ISUIA cohort) carrying particularly low rupture rates [2] . Aside from subarachnoid hemorrhage, aneurysms in the cavernous region and basal cisterns may occasionally cause cranial neuropathies, for example, a posterior communicating artery aneurysm compressing the oculomotor nerve. Thromboembolic stroke is an exceptionally rare presentation of an intracranial aneurysm, usually associated with giant or dissecting aneurysms. In the context of the relatively high prevalence of incidental saccular aneurysms (2%-4% in the general population), ischemic stroke is far more often coincidental rather than causally related, making diagnosis of an aneurysm-related embolic source challenging [3,4] . Reports of acute intra-aneurysmal thrombosis producing cerebral infarction and subsequently managed by endovascular intervention remain exceedingly scarce. Here, we present a rare case of an MCA bifurcation aneurysm with spontaneous intra-aneurysmal thrombosis presenting as ischemic stroke. Initial computed tomography angiography (CTA) findings were confusing, but th

FAQs

Why is ischemic stroke from MCA bifurcation aneurysms difficult to manage?

Because spontaneous intra-saccular thrombosis is extremely rare, clinicians must balance the risk of further thromboembolism against the danger of aneurysm rupture.

What imaging supported the diagnosis in this case?

Computed tomography angiography suggested an atypical luminal contour, while vessel wall MRI supported intra-aneurysmal thrombosis and aneurysm instability, alongside interval change on serial conventional angiography.

What treatment was used and what were the results?

Endovascular flow diversion was performed across the aneurysm into the superior division, with dual antiplatelet therapy initiated. The procedure was well tolerated and produced excellent angiographic results.

Sep 30, 2026

Uploaded by Jasmine

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