Introduction/Purpose Middle cerebral artery (MCA) bifurcation aneurysms rarely present with ischemic stroke, especially when associated with intra‐aneurysmal thrombosis. The management of such cases is not well‐defined and poses unique therapeutic and diagnostic challenges. This report aims to describe a rare case of a thrombosed MCA bifurcation aneurysm presenting with acute ischemic stroke managed through endovascular flow diversion. Materials/Methods A 68‐year‐old patient presented with acute left MCA territory infarction and neurological deficits. Initial computed tomography angiography (CTA) demonstrated a left MCA bifurcation aneurysm with an atypical luminal contour, suggesting thrombus. Vessel wall magnetic resonance imaging (MRI) indicated aneurysm instability. The patient underwent endovascular flow diversion across the aneurysm into the superior division, performed under dual antiplatelet therapy. All procedures and imaging data were reviewed by a multidisciplinary team. Results The flow diverter device was successfully deployed, achieving good flow diversion and progressive stasis of the aneurysm sac, with no intra‐procedural complications. Post‐procedural CTA at 48 hours confirmed stable device position and persistent aneurysm sac opacification; neurological recovery was uneventful. The patient was discharged on dual antiplatelet therapy and transitioned to monotherapy after six months. Long‐term follow‐up, via family report at two years, indicated the patient remained clinically well. Conclusion The treatment of partially thrombosed MCA bifurcation aneurysms presenting with ischemic stroke is challenging. Flow diversion appears to be a viable strategy when there is concurrent risk of thromboembolic events and rupture. Further data collection and experience, ideally via multicenter registries, are essential to clarify optimal management for this rare presentation. Graphics/Tables : Figure 1. Diffusion‐weighted imaging sequence demonstrating infarcts across the left cerebral hemisphere. Figure 2. CTA showing a filling defect within a saccular MCA bifurcation aneurysm. image image
Agwu et al. (Sat,) studied this question.