A Hybrid Approach for the Treatment of a Pure Arterial Malformation Located at an Accessory Middle Cerebral Artery. Cerebral Revascularization Followed by Endovascular Occlusion Using nBCA: Case Report.

Background and importance: Pure arterial malformations (PAMs) are rare vascular lesions with unknown natural history. Described in 2013 and initially considered benign, recent evidence of ruptured cases and progressive angioarchitectural changes may support the need for interventional treatment for selected patients. We present the first case of an accessory middle cerebral artery PAM successfully treated using a hybrid approach, including microsurgical revascularization and endovascular occlusion using Glubran2/Lipiodol.

Clinical presentation: A 58-year-old woman with a history of spontaneous basal ganglia hemorrhage 2 years before presented to our clinic with a dilated, multilobulated, and overlapping lesion located at a dominant left accessory middle cerebral artery, compatible with the diagnostic criteria of a PAM. The lesion was near the previous bleeding site, and since perforating and cortical vessels arose from its distal lobule, a safeguarding superficial temporal artery-MCA bypass was considered necessary before the successful endovascular embolization of the malformation using nBCA (Glubran2/Lipiodol).

Conclusion: PAMs can be associated with intracranial bleeding; thus, active treatment is warranted for selected patients. A hybrid microsurgical-endovascular approach is feasible and can be considered the optimal treatment for specific complex anatomies.