Two cases of distal anterior cerebral artery aneurysm associated with accessory anterior cerebral artery

An accessory anterior cerebral artery (accessory ACA) is a rare anomalous vessel arising from the anterior communicating artery as a median artery of triplicated ACA. It is considered a large median artery of the corpus callosum and distributes to one or both hemispheres. The cases of an accessory ACA aneurysm are extremely rare; however, we experienced two cases of unruptured aneurysm growing at the distal portion of an accessory ACA. Two females, aged 66 and 67 years, respectively, separately consulted our hospital as a result of chronic headaches. Brain MR angiography and following DSA in the first patient demonstrated a triplicated ACA and an aneurysm located just above the corpus callosum growing from the distal portion of the accessory ACA. MRI and MR angiography in the second patient depicted a triplicated ACA and an aneurysm from the accessory ACA as with the first case. Neck clipping of the aneurysm was performed using an interhemispheric approach in both cases. These aneurysms appeared to present the same intraoperative findings as other unruptured aneurysms growing at the usual positions.     

Posterior inferior cerebellar artery aneurysm associated with persistent primitive hypoglossal artery

A 49-year-old woman presented with subarachnoid hemorrhage (SAH) from an aneurysm associated with a persistent primitive hypoglossal artery (PPHA) manifesting as sudden onset of headache, but without neurological deficits. Conventional computed tomography (CT) of her head showed no abnormality but lumbar tap indicated SAH. Three-dimensional (3D)-CT angiography showed a PPHA originating from the internal carotid artery and an aneurysm of the posterior inferior cerebellar artery at the junction with the remnant hypoplastic vertebral artery. 3D-CT angiography was essentially useful for presurgical planning to determine the extent of craniotomy and the space for possible temporary clipping, and confirmed the diagnosis of aneurysmal SAH. The aneurysm was clipped and she returned to her job 4 weeks later. Cerebral angiography is the golden standard technique to diagnose PPHA, but 3D-CT angiography can be recommended for presurgical evaluation, especially in patients with complex and anomalous anatomical structures.     

Endovascular treatment of primitive persistent trigeminal artery aneurysm associated with middle cerebral artery aneurysm

We report the case of a primitive trigeminal artery aneurysm associated with an ipsilateral middle cerebral artery aneurysm. A 64-year-old Caucasian woman suffered from a severe acute headache. A head CT scan displayed subarachnoid hemorrhage and subsequent cerebral angiography showed right, wide-necked persistent trigeminal artery and ipsilateral middle cerebral artery aneurysms. The patient underwent embolization of both aneurysms with Guglielmi detachable coils. The association of a PPTA aneurysm and an ipsilateral MCA aneurysm has not been reported in the English literature.     

New variant of persistent primitive olfactory artery associated with a ruptured aneurysm

The authors present the case of a 78-year-old man who presented with a subarachnoid hemorrhage due to rupture of an aneurysm at the origin of the persistent primitive olfactory artery (PPOA). Interestingly, the PPOA was originating from the A1 segment of the anterior cerebral artery and coursed anteromedially along the olfactory tract. Moreover, the PPOA in this case had 2 branches: the branch making a hairpin turn and supplying the distal part of the anterior cerebral artery territory (Type 1), and the branch extending to the cribriform plate to supply the nasal cavity (Type 2). To the best of the authors' knowledge, this is a new variant (Type 3) of PPOA associated with a ruptured aneurysm. The clinical implications of this case are discussed in terms of the embryological aspects.     

Splitting of the optic nerve associated with ruptured anterior communicating artery aneurysm

A 52-year-old man presented with an anterior communicating artery aneurysm associated with splitting, penetration, and visual symptoms of the optic nerve and manifesting as sudden onset of severe headache. Angiography disclosed a 10-mm anterior communicating artery aneurysm projecting supero-posteriorly, and operative findings revealed unexpected splitting of the optic nerve. Moreover, the optic nerve was not in direct contact with the aneurysm fundus. Splitting of the optic nerve without the presence of a penetrating aneurysm is extremely rare. The pathogenesis of optic nerve penetration may involve congenital fenestration of the optic nerve.     

Ruptured anterior communicating artery aneurysm associated with anterior cranial fossa dural arteriovenous fistula--case report

A 77-year-old man presented with an extremely rare association of anterior cranial fossa dural arteriovenous fistula (AVF) with anterior communicating artery (ACoA) aneurysm manifesting as consciousness deterioration due to intracerebral hemorrhage in the left frontal lobe and diffuse subarachnoid hemorrhage. Angiography confirmed the association of a dural AVF fed by both ethmoidal arteries and an ACoA aneurysm. Surgery for these two lesions was performed concurrently, and the ACoA aneurysm was found to be responsible for the hemorrhage. This association seems incidental, but is clinically significant since the preoperative determination of the bleeding point is difficult. We conclude that these two lesions should be treated simultaneously, to avoid leaving the ruptured point untreated.     

Unusual intercarotid anastomosis associated with anterior communicating artery aneurysm. Case report

The case is presented of a 34-year-old man with subarachnoid hemorrhage from rupture of an anterior communicating artery aneurysm. The magnetic resonance imaging and angiographic findings are reported. Angiography showed the aneurysm plus an unusual anastomosis between the intracavernous portions of both internal carotid arteries. The anastomosis crossed posterior to the base of the dorsum sellae and was associated with absence of the right internal carotid artery and the A1 segment of the right anterior cerebral artery. This is the 11th case of such an unusual intercarotid anastomosis reported in the literature.     

Endovascular treatment of AVM-associated aneurysm of anterior inferior cerebellar artery through persistent primitive hypoglossal artery

We present a patient with the combination of persistent primitive hypoglossal artery and the origin of left common carotid artery from the brachiocephalic trunk, who had subarachnoid haemorrhage caused by a ruptured aneurysm. The aneurysm was on distal anterior inferior cerebellar artery which was a feeder to cerebellar arterio-venous malformation.     

Fusiform aneurysm of the anterior communicating artery

Fusiform aneurysms have often been reported on the internal carotid or vertebrobasilar arteries, but those solely involving the more distal segment of a cerebral artery seem to be exceptional. In a patient harboring two saccular cerebral aneurysms, angiography of the carotid arteries revealed a fusiform dilatation restricted to the anterior communicating artery. At autopsy, this dilatation proved to be a fusiform aneurysm.     

Endovascular coil embolization for ruptured aneurysm associated with persistent primitive anterior choroidal artery--case report

An 18-year-old man presented with a rare case of a ruptured internal carotid artery (ICA)-persistent primitive anterior choroidal artery (PPAchA) manifesting as sudden onset of headache. Computed tomography (CT) showed subarachnoid hemorrhage. Three-dimensional CT angiography showed a saccular aneurysm at the right ICA-AchA region. Right internal carotid angiography showed a PPAchA and saccular aneurysm. Endovascular treatment of the aneurysm achieved complete aneurysm occlusion.     

Unilateral oculomotor nerve paresis associated with anterior communicating artery aneurysm rupture--two case reports

Two cases of complete unilateral oculomotor nerve palsy occurred after subarachnoid hemorrhage (SAH) due to a ruptured anterior communicating artery aneurysm. A 61-year-old female suffered left oculomotor nerve paresis after mild SAH. This paresis was probably related to pre-existing oculomotor nerve stretching caused by abnormal positioning of the posterior cerebral and superior cerebellar arteries in the premesencephalic cistern. A 70-year-old female suffered right oculomotor nerve paresis after severe SAH. Elevated intracranial pressure might have caused this paresis, but the reason for the unilateral occurrence was undetermined. Both patients were treated by clipping of the aneurysm, and the signs of oculomotor nerve paresis gradually resolved. A pattern of pupil-sparing paresis was observed during the early recovery stage in both patients.     

A large anomalous anterior choroidal artery associated with internal carotid artery-posterior communicating artery aneurysm.

A case of a large anomalous anterior choroidal artery (AchA) associated with internal carotid artery-posterior communicating artery aneurysm is reported. At surgery, the large anomalous AchA mimicked the PcomA. Therefore, we initially mistook the large anomalous AchA for the PcomA, and the ICA-PcomA aneurysm for the dorsal ICA aneurysm arising at a location of other than an arterial division. This is a rare case of an anomaly of the AchA with an associated aneurysm found at surgery. Anatomical and surgical considerations are made.     

Giant aneurysm of the distal anterior cerebral artery: associated with an anterior communicating artery aneurysm and a dural arteriovenous fistula.

We describe an unusual case of a giant pericallosal artery aneurysm, producing psychomotor depression from mass effect, associated with a smaller aneurysm of the anterior communicating artery, a dural arteriovenous fistula, and a meningioma. Magnetic resonance imaging (MRI) and cerebral angiography demonstrated the giant aneurysm and the meningioma. Cerebral angiography provided a detailed appreciation of the cerebral circulation, including both aneurysms, the dural arteriovenous fistula, and the potential collateral supply to the involved anterior cerebral distribution. The anterior communicating artery aneurysm was successfully clipped as was the distal anterior cerebral branch supplying the giant aneurysm before its resection. The patient made a full recovery but with persisting, slight dysphasia. We conclude that computed tomography, cerebral angiography, and MRI are of specific value in the assessment of giant aneurysms, but only angiography can provide detailed characterization of the aneurysm and demonstrate other possible cerebrovascular pathology such as multiple aneurysms and arteriovenous fistulas.     

Ruptured anterior communicating artery aneurysm. Therapeutic options in 119 consecutive cases

BACKGROUND AND PURPOSE: The respective roles of endovascular and surgical treatment must be clearly defined in the management of ruptured anterior communicating artery (AcoA) aneurysm. The aim of our study was to report our results, using the aneurysm direction as the main morphological argument to choose between microsurgery and endovascular embolization. Morbidity and mortality, causes of unfavorable outcome and morphological results were also assessed. PATIENTS AND METHODS: Our prospective study included 119 patients: 89 treated by microsurgery and 30 undergoing embolization with Guglielmi Detachable Coils (GDC). When the aneurysm had an anterior direction (fundus of the aneurysm in front of the pericallosal arteries), we attempted microsurgery. If the fundus of the aneurysm was behind the pericallosal arteries, we selected the most adapted procedure after discussion with the neurovascular team, taking into account the physiological status, treatment risk and neck size. Preoperative status of the patients was assessed according to the Hunt and Hess (HH) classification. Cerebral CT-scan and angiograms were routinely performed after treatment to determine causes of unfavorable outcome (GOS>1) and the morphological results. RESULT: Overall clinical outcome was excellent (GOS1) for 63.0% of patients, good (GOS2) for 10.1%, fair (GOS3) for 13.4%, poor (GOS4) for 2.5%. The mortality rate was 10.9%. Among the 82 patients in good preoperative grade (HHIII), 8 (21.6%) achieved an excellent outcome. However permanent morbidity or death occurred in 15 patients (78.4%). Permanent disability and death were related to initial subarachnoid hemorrhage and were observed 21.3% of patients in the microsurgical group and 30.0% in the endovascular group [Fisher's Exact Test; p=0.33]. Procedure-related permanent disability and death rates were 9.0% for the microsurgical group and 23.3% for the endovascular group (p=0.06) respectively. In the microsurgical group, the only morphologic characteristic which significantly correlated with the occurrence of vessel occlusion was the fundus direction (p=0.03). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (p=0.04). CONCLUSION: In our experience, the direction of the aneurysm was the main morphological criterion in choosing between microsurgery or endovascular procedure for the treatment of AcoA aneurysm. We propose that microsurgical clipping should be preferred for AcoA aneurysms with anterior direction, and depending on morphological criteria, endovascular packing for those with posterior direction.     

126例前交通动脉瘤的介入治疗

目的：探讨前交通动脉瘤介入治疗的特点,以提高临床疗效。方法：经血管内途径,采用可脱性弹簧圈对126例前交通动脉瘤患者行栓塞治疗,未能栓塞者多数行手术治疗。结果：成功栓塞109例,其中100％闭塞97例,95％－98％闭塞12例。17例栓塞未成功者,行外科手术治疗15例,2例因脑血管痉挛而未进行处理。123例患者治疗后痊愈;1例死亡;2例栓塞失败后未进行治疗的患者,分别随访5个月及1年,动脉瘤自愈。本组32例治疗后获随访3周－30个月,行脑血管造影,30例动脉瘤未见显影;2例复发,经再次栓塞后治愈。结论：多数前交通动脉瘤可经血管内栓塞治愈,不能行血管内治疗的可行外科手术治疗,极少数病例可自愈,但远期效果仍需行长期随访观察。     

Ruptured internal carotid -posterior communicating artery aneurysm associated with an anomalous hyperplastic anterior choroidal artery and aneurysm: case report

We report a rare case of a ruptured internal carotid-posterior communicating artery (IC-PcomA) aneurysm associated with an anomalous hyperplastic anterior choroidal artery (AchoA) and aneuysm. A 64-year-old woman was admitted to our hospital because of a sudden onset of headache. CT scan showed subarachnoid hemorrhage. Left internal carotid angiograms showed a saccular aneurysm at the IC-PcomA region. Left posterior cerebral artery filling from the fetal type PcomA and an anomalous hyperplastic AchoA originating from the internal carotid artery (ICA) were also revealed. Left vertebral angiograms (Allcock test) revealed the left ICA and an anomalous hyperplastic AchoA via the fetal type PcomA. The patient was surgically treated through the left pterional transsylvian approach. The ruptured aneurysm was observed at the IC-PcomA region. The unruptured small aneurysm was found on just distal to the ruptured aneurysm. The PcomA and an anomalous hyperplastic AchoA were not observed behind the ICA. To prevent bleeding, the ruptured aneurysm and unruptured small aneurysm were clipped. Postoperative left internal carotid angiograms demonstrated no aneurysm was observed at the IC-PcomA region. The patency of the fetal type PcomA and an anomalous hyperplastic AchoA were preserved. The 7 reported cases of a intracranial aneurysm associated with an anomalous hyperplastic AchoA with our case are reviewed and their neuroradiological and clinical features are discussed.     

Ruptured anterior communicating artery aneurysms associated with fenestration of the anterior cerebral artery

Two patients with ruptured anterior communicating artery aneurysms associated with fenestration of the anterior cerebral artery are reported. In the literature, only 12 angiographic demonstrations of fenestration of the anterior cerebral artery have been reported. All fenestrations were limited to the distal half of the A1 portion, and seven of the 12 cases were associated with aneurysms. The high incidence of coexisting fenestration and aneurysm suggests that congenital factors may play a role in the pathogenesis of cerebral aneurysm.