Saccular bilobed aneurysm of an azygos anterior cerebral artery.

An azygos anterior cerebral artery is an anatomical variant in which the anterior communicating artery is absent and both the A1 segments unite to form a single A2 segment of the artery. This anatomical variant may be associated with holoprosencephaly and may predispose to aneurysm formation, however the association of such an anomaly with an aneurysm is rare. When associated with an aneurysm, it poses management difficulties due to the single distal anterior cerebral artery. Most of the reported aneurysms with such an anomaly are saccular and located in the distal part of the artery. We report a patient with a wide neck saccular multilobed aneurysm who presented after a grade 3 subarachnoid haemorrhage. A right pterional craniotomy and clipping of the aneurysm was performed following cerebral angiography. The mechanism of formation and difficulties in management of such an aneurysm is discussed.     

Intracranial saccular aneurysm: report of 3 cases in a same family]

The authors report the cases of three patients from the same family, all with intracranial saccular aneurysm (left carotid artery, anterior communicating artery, and middle cerebral artery). All three patients were operated on with good recovery and no complications. The authors call attention for some etiopathogenic aspects of familial saccular aneurysms.     

Multiple aneurysms associated with bilateral carotid occlusion and venous angioma: surgical management risk-case report.

A unique case of multiple aneurysms associated with bilateral carotid artery occlusion and venous angioma is described. A 42 year old female presented with subarachnoid haemorrhage. Cerebral angiograms demonstrated(1) a ruptured saccular aneurysm in the right posterior cerebral artery,(2) bilateral occlusion of internal carotid arteries,(3) a rete mirabile in the subtemporal fossa fed by left external carotid artery which connected with the internal carotid artery at the cavernous portion where a saccular aneurysm had formed, and(4) a venous angioma in the posterior fossa. The ruptured aneurysm of the posterior cerebral artery was obliterated preserving the anterior choroidal arteries. However, a left hemiparesis developed and CT scan revealed a small low density area in the right posterior limb of the internal capsule postoperatively. A ruptured aneurysm associated with bilateral extracranial carotid occlusion poses a clinical dilemma and treatment of such cases is challenging and difficult. The non-surgical and surgical outcomes of ruptured cerebral aneurysms associated with internal carotid occlusion are reviewed.     

Incidence of intracranial aneurysms in north-west Indian population

One thousand human brains of both sexes were examined. Aneurysms were found in 10 specimens (1%). The incidence of aneurysms was 1.6% in females and 0.8% in males. All the aneurysms were saccular. The aneurysms varied in size. In 5 specimens the aneurysms were minute bulbous dilatations. In the rest of the cases it varied from 0.2 to 2.5 cm. In 7 specimens the aneurysms were present at the junction of anterior cerebral artery with the anterior communicating artery, in 2 on the anterior communicating artery and in one specimen it was seen at the origin of posterior communicating artery. The youngest subject with saccular aneurysm was an 18-years-old male and the oldest was a 55-years-old male. No aneurysm was found in the brains of 94 children (1-17 years).     

Ruptured Saccular Aneurysm Arising from Fenestrated Proximal Anterior Cerebral Artery : Case Report and Literature Review

The aneurysm arising from fenestrated proximal anterior cerebral artery (ACA) is considered to be unique. The authors report a case of a 59-year-old woman who presented with a subarachnoid hemorrhage (SAH) secondary to a ruptured aneurysm originating from the fenestrated A1 segment of right ACA. The patient had another unruptured aneurysm which was located at the right middle cerebral artery bifurcation. She was successfully treated with surgical clipping for both aneurysms. From the previously existing literatures, we found 18 more cases (1983-2011) of aneurysms associated with fenestrated A1 segment. All cases represented saccular type of aneurysms, and 79% of the patients had SAH. There were three subtypes of the fenestrated A1 aneurysms depending on the anatomical location, relative to the fenestrated segment. The most common type was the aneurysms located on the proximal end of fenestrated artery (82%). Azygos ACA and hypoplastic A1 were frequently accompanied by the aneurysm (33% and 31%, respectively), and multiple aneurysms were shown in three cases (16%). Considering that fenestrated A1 segment is likely to develop an aneurysm, which has high risk of rupture, early management may benefit patients with aneurysms accompanied by fenestrated proximal ACA.     

Saccular Aneurysm at the Anterior Communicating Artery Complex Associated with an Accessory Middle Cerebral Artery : Report of Two Cases and Review of the Literature

Accessory middle cerebral artery (MCA) is an infrequent vascular anomaly of the brain. Cerebral aneurysms associated with this anomalous artery are also very rare. To our knowledge, there have only been ten previous reports of an aneurysm associated with accessory MCA. The authors present two patients with accessory MCA-related aneurysms. A 38-year-old male and a 59-year-old female both presented with sudden-onset severe headache. In both patients, computed tomography (CT) scan revealed subarachnoid hemorrhage. A subsequent angiogram demonstrated an accessory MCA arising from the anterior cerebral artery (ACA) and a saccular aneurysm at the anterior communicating artery (ACoA) complex associated with an accessory MCA. Surgical clipping allowed for complete exclusion of the aneurysm from the arterial circulation. Based on our review of the ten cases of aneurysms associated with accessory MCA documented in the literature, we suggest that accessory MCA-related aneurysms can be classified according to whether the accessory MCA originates from the proximal A1 segment or from the ACoA complex. We also emphasize the importance of precise interpretation of preoperative angiograms and intraoperative precaution in determining the presence of this anomalous artery prior to temporary clip placement.     

Infraoptic Course of Both Anterior Cerebral Arteries

A 28-year-old woman was referred to our hospital with a sudden, very severe headache. Brain computed tomographic angiography showed a saccular cerebral aneurysm at the bifurcation of the left middle cerebral artery and infraoptic courses of both anterior cerebral arteries. The anterior cerebral arteries were seen to arise from the ipsilateral internal cerebral arteries at the level of the origin of the ophthalmic artery, passed underneath the ipsilateral optic nerve, and turned upward at ventral portion of the optic chiasm.Infraoptic course of the proximal anterior cerebral artery is an extremely rare anomaly and is often associated with cerebral aneurysms. We report the clinical features, radiological findings, and possible genesis of this anomaly with a literature review.     

Intraaneurysmal embolization of an unruptured basilar tip aneurysm associated with moyamoya disease.

We describe a patient with moyamoya disease associated with an unruptured basilar tip aneurysm which was treated by endovascular embolization using Guglielmi detachable coils (GDCs). A 53-year-old man presented with left hemiparesis persisting for 3 mon ths before admission. Cerebral angiography revealed occlusion of the bilateral middle cerebral arteries and the left anterior cerebral artery, stenosis of the right anterior cerebral artery, and basal moyamoya vessels. In addition, a saccular small aneurysm was seen at the top of the basilar artery. The aneurysm was completely embolized by intraaneurysmal GDCs. Direct surgical clipping is often selected for the treatment of posterior fossa aneurysms in moyamoya disease. However, complete clipping is usually difficult due to the difficulties in operative technique associated with moyamoya disease. We suggest that the endovascular treatment using GDCs is comparatively safe and effective for the treatment of surgically difficult aneurysms in patients with moyamoya disease.     

Prevalence of intracranial saccular aneurysms in a Japanese community based on a consecutive autopsy series during a 30-year observation period. The Hisayama study.

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage is a life-threatening disease that occurs mostly because of the rupture of intracranial saccular aneurysms. However, little is known about the prevalence of ruptured and unruptured aneurysms in the general population. The aim of the present study was to examine the prevalence of intracranial aneurysms on the basis of a consecutive autopsy series over a 30-year observation period in a general Japanese population in Hisayama. METHODS: We evaluated 1230 consecutive autopsy cases with craniotomy among the total deaths of Hisayama residents during 1962 through 1991 (overall autopsy rate, 80.1%). RESULTS: A total of 73 intracranial saccular aneurysms were found in 57 cases (4.6%). The prevalence of aneurysms for women was 2.4 times higher than that for men (7.1% versus 2.9%). Among men, the prevalence of aneurysms remained unchanged across the range of age groups. In contrast, there were 2 peaks in the prevalence of aneurysms for women falling in the 40- to 49-year (14.3%) and 60- to 69-year age groups (14.5%). The most common site of the aneurysms was the middle cerebral artery (31.5%), followed by the anterior communicating artery (30.1%), anterior cerebral artery (15.1%), vertebrobasilar artery (12.3%), and internal carotid artery (11.0%). Among these 73 aneurysms, 29 (39.7%) were ruptured. Ruptured aneurysms were common in subjects <80 years of age, whereas unruptured aneurysms were prevalent in those >/=80 years of age. The frequency of ruptured aneurysms was highest in the vertebrobasilar system (66.7%) and lowest in the middle cerebral artery (13.0%). CONCLUSIONS: Our data suggest that intracranial aneurysms are more frequent in women in the general Japanese population. Aneurysms are more prevalent in the middle cerebral artery, but the risk of rupture is highest in the vertebrobasilar system.     

大脑前动脉A1优势征与前交通动脉瘤关系的临床研究

目的探讨大脑前动脉（ACA）A1优势征与前交通动脉瘤的发生及生长方向之间的关系。方法回顾性分析500例数字减影脑血管造影的影像学资料,其中前交通动脉瘤128例,其他部位的动脉瘤244例,其余非动脉瘤患者128例。比较各组间A1优势征发生率的差别;同时比较A1优势征与A1对称患者动脉瘤生长方向的区别。结果全脑血管造影显示A1优势征的发生率在前交通动脉瘤患者为63.3%;其它部位动脉瘤患者为17.6%,非动脉瘤患者为20.3%。前交通动脉瘤中A1优势征的出现率明显高于其他两组（P〈0.05）。A1优势征的前交通动脉瘤向前上生长者明显高于A1对称者,分别为53.1%和31.9%（P〈0.05）;向后下、后上方的生长者总计少于A1对称者,分别为22.2%和42.6%（P〈0.05）。结论A1优势征与前交通动脉瘤的发生及生长方向密切相关。     

The anatomy of aneurysm-bearing circles of Willis

The circle of Willis is known to exhibit considerable anatomical variability. The incidence of variations of the circle is said to be greater when an aneurysm is present, particularly one of the anterior communicating artery. In this study 40 circles of Willis bearing 51 saccular aneurysms were dissected and examined macroscopically. Forty circles from patients with other neurological diseases served as controls. Ninety-seven per cent of circles bearing aneurysms showed variations from a hypothetical "normal" structure, as did 85% of controls. The aneurysm group as a whole, and circles bearing anterior communicating aneurysms, showed a higher incidence of anterior cerebral artery asymmetry than controls (p less than 0.001), as did the latter when compared with circles bearing aneurysms at other sites (p less than 0.01), but there were no other significant differences.     

Possible participation of clip rotation in the formation of de novo aneurysm.

During long term follow-up after successful treatment of ruptured intracranial aneurysms, a few patients develop newly formed (de novo) aneurysms, which account for 0.9-1.1% of all cerebral aneurysms. As for the etiology of de novo cerebral saccular aneurysms, hemodynamic stress is considered to be the most important factor. The woman whose case we present here had developed a ruptured anterior communicating aneurysm at the age of 52, and the aneurysm with its anterior projection was completely clipped. Eight years later, she suffered intraventricular hemorrhage. Angiogram showed a newly formed anterior communicating artery aneurysm, which projected to the side opposite the clip. Surgical exploration found the head of the clip had rotated and become trapped between optic nerves. We speculated the rotation of the clip used for the aneurysm at the first operation was one of the possible mechanisms, which caused a change in the direction of hemodynamics to the anterior communicating artery, leading to the development of de novo aneurysm. Every neurosurgeon should pay attention to the clip position until dural closure has been completed.     

A case of agenesis of the corpus callosum accompanied by a ruptured azygos anterior cerebral artery aneurysm and lipoma--a case report

A 53-year-old woman suffered from sudden onset of severe headache on February 28 in 1982. She was admitted to our hospital soon after onset. On admission, she had a severe headache and nausea, and her consciousness was drowsy. CT scan showed a marked subarachnoid hemorrhage with intracerebral and intraventricular hematoma, a separation of the lateral ventricles with enlargement of posterior horns, and deformity of anterior horn. By these findings, the patient was diagnosed as an agenesis of the corpus callosum with subarachnoid hemorrhage. Left carotid arteriogram revealed an azygos anterior cerebral artery and an aneurysm at the terminal portion of this artery. Surgery was performed on the 24 th day after subarachnoid hemorrhage. Operative finding revealed a little finger's head-sized tumor was situated over the right frontobasal artery. An azygos anterior cerebral artery aneurysm was clipped and tumor was removed. Pathological diagnosis of the tumor was a lipoma. Namely, she had an agenesis of the corpus callosum, an azygos anterior cerebral artery, an aneurysm and a lipoma. There are some reports in which an agenesis of the corpus callosum is accompanied with a lipoma and an azygos anterior cerebral artery is accompanied with an aneurysm. But a case of agenesis of the corpus callosum with an azygos anterior cerebral artery was rarely reported. So this rare case with these anomalies was reported and pathogenesis about the development of 4 anomalies was also discussed.     

Endovascular treatment of posterior cerebral aneurysm associated with Moyamoya disease

PURPOSE: A patient with moyamoya disease associated with a ruptured posterior cerebral artery aneurysm treated by endovascular embolization is presented. CASE REPORT: A 47-year-old woman was admitted with severe headache to our hospital. Computed tomography demonstrated subarachnoid haemorrhage. Cerebral angiography revealed evidence of moyamoya disease and a saccular aneurysm at the P1 segment of the left posterior cerebral artery. CONCLUSION: Endovascular embolization was performed using Guglielmi detachable coil (GDC), and the aneurysm was completely occluded with preservation of the parent artery. Endovascular treatment using GDC seems comparatively safe and effective for the treatment of cerebral saccular aneurysms in patients with moyamoya disease.     

手术治疗大脑前动脉远端动脉瘤(附九例报告)

目的 探讨大脑前动脉远端动脉瘤(DACAA)的诊断和显微外科手术治疗.方法 回顾分析2007年10月至2010年3月显微手术治疗DACAA 9例.术前Hunt-Hess分级0级1例,Ⅰ级2例,Ⅱ级4例,Ⅲ级1例,Ⅳ级1例.结果 9例DACAA经额纵裂入路成功夹闭动脉瘤11个,动脉瘤直径在3～30 mm之间,其中囊性动脉瘤9个,梭形动脉瘤1个,巨大动脉瘤1个;位于A2段2个,A3段8个,胼周动脉末梢段1个.2例为多发动脉瘤,1例合并动静脉畸形.1例梭形动脉瘤患者术后出现对侧肢体偏瘫,余治疗效果满意,无手术死亡,亦无其他并发症.按照GOS预后评分,8例恢复良好,1例重残.结论 通过术前3D-CTA和DSA等影像学诊断和准确手术定位,经额纵裂入路显微手术夹闭DACAA效果满意.

Abstract：

Objective To report the clinical diagnosis and microsurgical treatment of ruptured distal anterior cerebral artery aneurysm(DACAA)patients treated over the last 3 years.Methods 9 consecutive cases of ruptured DACAA operated from October 2007 to March 2010 were reviewed and followed up.Methods 11 aneurysms were clipped through interhemispheric approach microsurgery in 9 cases with ruptured DACAA.The diameter of 11 aneurysms was between 3-30 mm.Of which 9 cases were saccular aneurysms,1 case was fusiform aneurysm and 1 case was giant aneurysm.There were 2 aneurysm located at A2 segment of the ACA,8 located at A3 and 1 located at distal pericallosal artery.So there were 2 cases with multiple aneurysms and 1 case combined with AVM.The clinical outcomes of these patients evaluated by Glasgow Outcome Scale were:Except 1 case of fusiform DACAA presented hemiplegic paralysis after the surgery,all 8 cases discharged without deficit and no mortality in the group.Conclusion Depending on precise understanding of angiography imaging and location of 3D- CTA and DSA,interhemispheric approach is a safe method to clip the DACAA.     

A case of symmetrical aneurysms at the bilateral middle cerebral arteries associated with the deep seated arteriovenous malformation in the midline]

A case of symmetrical aneurysms at the bilateral middle cerebral arteries (MCA) associated with the deep seated arteriovenous malformation (AVM) in the midline was presented. Because symmetrical aneurysms at the MCA are 1.17% of all aneurysms, and those associated with the deep seated AVM in the midline are very rare. A 75-year-old female suffered from a sudden onset of a severe headache and a loss of consciousness, and was admitted to our department on June 14, 1996. Computed tomography(CT) showed a subarachnoid hemorrhage (SAH) in the right sylvian fissure (Fisher's Group 4). Bilateral symmetrical MCA's aneurysms and the deep seated AVM were clarified by angiography. The symmetrical aneurysms stood out anterior lateral side and the right aneurysm had bleb. On the other hand, the afferent vessels of the AVM were the branches of bilateral posterior cerebral arteries, and the efferent vessel was the vein of Galen. So we determined SAH due to right MCA aneurysm, and performed the neck clipping of the ruptured aneurysm. The symmetrical aneurysms at the MCA associated with AVM in midline have not been reported. Each parent's artery was not connected each other. These origins, therefore, are suggested to be related not only to acquired factors like hypertension, hemodynamic stress etc, but also to a congenital factor. The origin of the saccular aneurysm is suggested congenital either but it isn't definite.     

Clinical analysis of vitreous hemorrhage combined with ruptured aneurysm

Eight cases of vitreous hemorrhage with ruptured intracranial aneurysm (Terson's syndrome) were experienced in our clinic from April, 1978 to April, 1983. They consisted of five males and three famales between 45 and 69 years old. All cases had unconscious attacks and three of them experienced repeated episodes of subarachnoid hemorrhage within 24 hours. CT scan, performed 24 hours within the attack, revealed remarkable high density areas at prepontine and suprasellar cisterns, interhemispheric and sylvian fissures. Ruptured aneurysms, confirmed by cerebral angiography and operative findings, were three anterior communicating artery aneurysms, three internal cerebral artery aneurysms, one middle cerebral artery aneurysm and one anterior cerebral artery aneurysm. We performed radical operation for the ruptured aneurysm, six cases at acute atage, one at 11 days and one at 18 days after the attack. Postoperative courses were all good. Five cases had bilateral vitreous hemorrhages and three had unilateral ones. At first they were treated conservatively. Visual acuity of six cases, 13 eyes improved gradually, but three cases, four eyes did not improve after four or five months after the attack. So we let ophthalmologist to perform vitrectomy, which showed effective results. Vitreous hemorrhage following a ruptured intracranial aneurysm is not a so rare complication than has been assumed and also its prognosis is not so poor. In most cases vitreous hemorrhage following a ruptured intracranial aneurysm should be treated conservatively, but in selected cases effective results would be given by vitrectomy.     

后循环动脉瘤的血管内介入治疗

目的探讨后循环动脉瘤血管内介入治疗的临床应用。方法 14例后循环动脉瘤患者Hunt&Hess分级分为Ⅱ级11例,Ⅲ级2例,Ⅳ级1例;数字减影血管造影(DSA)显示椎动脉瘤2例,小脑后下动脉远端动脉瘤5例,基底动脉尖动脉瘤2例,基底动脉末端动脉瘤1例,小脑前下动脉瘤2例,大脑后动脉瘤2例。入组者均给予血管内介入治疗,其中7例囊性动脉瘤采用单纯弹簧圈栓塞术,5例采用Onxy胶载瘤动脉局部栓塞术,分别有1例应用支架辅助微弹簧圈栓塞术及支架塑形术。结果术后DSA显示动脉瘤完全栓塞10例,近全栓塞3例。1例支架塑形术后梭形膨出明显好转。格拉斯哥预后量表评分为5分12例,3分1例,2分1例。随访3个月～5年,8例恢复正常,1例左侧偏瘫,1例死亡,4例失访。结论颅内后循环动脉瘤多为复杂动脉瘤,个体化血管内介入治疗是安全、有效的方法。     

Olfactory groove meningioma and multiple aneurysms. Case report.

We report a case of a patient with olfactory groove meningioma associated with multiple aneurysms. The association between intracranial aneurysms and meningiomas is infrequent and perhaps it is due to chance alone; many theories have been formulated to explain it. In the cases with both lesions, meningiomas are more frequently located at level of the convexity while aneurysms are more often located at level of the anterior cerebral-anterior communicating artery complex or at level of the middle cerebral artery.     

一次性开颅手术治疗颅内多发动脉瘤

报道７例颅内多发动脉瘤。每例均有２个动脉瘤，其中１３个为囊性，１个为梭形。有１例为双侧脉络膜前动脉对称性囊性动脉瘤。经单侧额颞开颅，翼点入路将全部囊性动脉瘤一次性夹闭。经术中瘤囊穿刺及术后动脉造影证实动脉瘤被完金夹闭。梭形动脉瘤仅用肌肉包裹。术后病人均恢复良好，无手术死亡和重残。结合我们的病例，本文对颅内多发性动脉瘤的识别、手术时机及手术方法进行了讨论，强调有条件时，对颅内多发性动脉瘤应及时一次性手术治疗。