A 48-year-old female presented with intermittent headache and right hemiparesis for 6 years. Non-contrast computed tomography of head revealed a space-occupying lesion (SOL) in left frontotemporal region which was partially calcified [ Figure 1a ]. Magnetic resonance imaging axial flair image showed layered thrombus inside the SOL [ Figure 1b ]. A provisional diagnosis of a partially thrombosed and partially calcified aneurysm was kept and computed tomography angiography [Figure 1c and d ] revealed an aneurysm arising from left middle cerebral artery (MCA). There was a significant calcified portion of aneurysm. Digital subtraction angiography [Figure 1e and f ] showed an aneurysm arising from left MCA. There appeared to be a significant nonfilling portion which was apparent due to displacement of one of the branches of MCA (shown by arrow heads). Magnetic resonance angiography [ Figure 1g ] revealed that a small central portion of the aneurysm was filling (shown by arrow) while the rest of the mass was not taking up contrast (shown by arrow heads). A diagnosis of giant partially thrombosed and partially calcified aneurysm arising from left MCA was kept. The size was 5.1 × 4.0 × 3.2 cm. The patient was taken up for surgery. Anticipating difficult direct clipping, superficial temporal artery (STA) was harvested before craniotomy. During surgery, we attempted direct clipping of the aneurysm after applying a proximal temporary clip and suction decompression. However, calcification at the neck lead to unsuccessful direct clipping. Therefore, trapping of the aneurysm was done. Along with it, STA-MCA bypass (low flow) to one of the MCA trunks was done. The patient remained well in the postop period and was discharged in the same clinical condition as preoperative.

Figure 1

(a) NCCT reveals SOL in left fronto temporal region which was partially calcified. (b) MRI axial flair image shows layered thrombus inside the SOL. (c and d) CT angiography shows an aneurysm arising from MCA with significant calcification. DSA of Left ICA (e) oblique view and (f) lateral view showing a large filling aneurysm arising from left MCA(arrow). In addition, there is a large non filling portion (?thrombosed ) of aneurysm shown by arrow heads. (g) MR angiography reveals central filling portion (Arrow) while the rest of the mass was not taking up contrast (Arrow heads)

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