• Tao Tao, Wei Dai, Wei Li, and Chun-Hua Hang.
• Department of Neurosurgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China.
• World Neurosurg. 2020 Jan 1; 133: 21-24.

BackgroundGiant serpentine aneurysms that occur in the distal anterior cerebral artery are extremely rare and challenging to manage because of their complex structure. In this case, we show an aneurysm resection performed after in situ side-to-side A3-A3 bypass to treat a giant serpentine distal anterior cerebral artery aneurysm.Case DescriptionHere, we present the case of a 55-year-old man with a giant distal anterior cerebral artery serpentine aneurysm who presented with severe headache and progressive unconsciousness. Computed tomography and cerebral angiography revealed a giant serpentine aneurysm in the right A2 segment. Both the right pericallosal and callosal marginal arteries branched from the outflow tract. To relieve the mass effect and preserve distal blood flow, an in situ side-to-side A3-A3 anastomosis and a partial aneurysm resection were performed sequentially. Postoperative cerebral angiography revealed no aneurysm blood filling and good perfusion in both anterior cerebral artery territories.ConclusionsAnterior cerebral artery giant serpentine aneurysms are rare and usually present with headache and mass effect. Aneurysm resection and distal flow protection are issues that we must consider. The sequential procedure of anastomosis and aneurysm resection is a feasible and safe option.Copyright © 2019. Published by Elsevier Inc.

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