Surgical Experience of the Ruptured Distal Anterior Cerebral Artery Aneurysms

Objective

Distal anterior cerebral artery (DACA) aneurysms are fragile and known to have high risks for intraoperative premature rupture and a relatively high associated morbidity. To improve surgical outcomes of DACA aneurysms, we reviewed our surgical strategy and its results postoperatively.

Methods

A total of 845 patients with ruptured cerebral aneurysms were operated in our hospital from January 1991 to December 2005. Twenty-three of 845 patients had ruptured DACA aneurysms which were operated on according to our surgical strategy. Our surgical strategy was as follows; early surgery, appropriate releasing of CSF, appropriate surgical approach, using neuronavigating system, securing the bridging veins, using temporary clipping and/or tentative clipping, meticulous manipulation of aneurysm, and using micro-Doppler flow probe. Twenty of 23 patients who had complete medical records were studied retrospectively. We observed the postoperative radiographic findings and checked Glasgow Outcome Scale score sixth months after the operation.

Results

Nineteen DACA aneurysms were clipped through a unilateral interhemispheric approach and one DACA aneurysm was clipped through a pterional approach. Postoperative radiographic findings revealed complete clipping of aneurysmal neck without stenosis or occlusion of parent arteries. In two patients, a residual neck of aneurysm was visualized. Seventeen patients showed good recovery, one patient resulted in moderate disability, while 2 patients died.

Conclusion

With our surgical strategy it was possible to achieve acceptable surgical morbidity and mortality rates in patients with DACA aneurysms. Appropriate use of tentative clipping, temporary clipping and neuro-navigating systems can give great help for safe approach and clipping of DACA aneurysm.     

Neuroform Stent-Assisted Coil Embolization of a Ruptured A1 Segment Anterior Cerebral Artery Aneurysm

We report a case of a 71-year-old woman who presented with a ruptured wide-necked proximal anterior cerebral artery (ACA) aneurysm that was successfully embolized using Neuroform stent-assisted coiling.     

Successful Obliteration of Unclippable Large and Giant Middle Cerebral Artery Aneurysms Following Extracranial-Intracranial Bypass and Distal Clip Application

Large to giant middle cerebral artery aneurysm is a challenging disease, especially when incorporating important perforating arteries. Surgical risk increases by perforator infarction and anatomical complexity. In this clinical setting, extensive consideration of surgical options is needed. The two cases described here were unruptured and had rather stable wall. Because of their large and giant size, hardness and incorporated arteries, it was not affordable to isolate them by means of clipping or trapping. The procedure as the alternative to conventional treatment modalities, extracranial-intracranial bypass followed by clipping of only the efferent artery successfully treated the aneurysms.     

Saccular Aneurysm of the Azygos Anterior Cerebral Artery: Three Case Reports

The azygos anterior cerebral artery, a rare anomaly in the circle of Willis in which only a single vessel supplies the medial aspects of both anterior cerebral hemispheres, is closely associated with saccular aneurysms. We present three cases of azygos anterior cerebral artery aneurysms among the 781 cerebral aneurysms surgically treated at our institution in an 11-year period. These three cases all involved elderly women who presented with subarachnoid hemorrhage. Conventional cerebral angiography and CT angiography revealed small saccular aneurysms at the distal ends of the azygos anterior cerebral arteries. These aneurysms were clipped successfully using a bifrontal interhemispheric approach. Hence, the pathogenesis of these particular aneurysms relating to hemodynamic change, associated anomalies, and surgical pitfalls is discussed with review of literature.     

Giant Serpentine Aneurysm of the Middle Cerebral Artery

Giant serpentine aneurysms are rare and have distinct angiographic findings. The rarity, large size, complex anatomy and hemodynamic characteristics of giant serpentine aneurysms make treatment difficult. We report a case of a giant serpentine aneurysm of the right middle cerebral artery (MCA) that presented as headache. Treatment involved a superficial temporal artery (STA)-MCA bypass followed by aneurysm resection. The patient was discharged without neurological deficits, and early and late follow-up angiography disclosed successful removal of the aneurysm and a patent bypass graft. We conclude that STA-MCA bypass and aneurysm excision is a successful treatment method for a giant serpentine aneurysm.     

Traumatic Aneurysm of the Callosomarginal Artery-Cortical Artery Junction from Penetrating Injury by Scissors

Traumatic intracranial aneurysms (TICAs) are rare and are associated with high rates of morbidity and mortality. TICAs usually result from head injuries caused by traffic accidents, industrial accidents, or gunshots. We report a traumatic aneurysm of the callosomarginal artery-cortical artery junction arising from a penetrating injury by scissors. A 51-year-old woman was admitted to our hospital after suffering a penetrating injury caused by scissors. Computed tomography (CT) and CT-angiography demonstrated a right orbital roof fracture, subarachnoid hemorrhage, frontal lobe hemorrhage, intraventricular hemorrhage, and a traumatic aneurysm of the right callosomarginal artery-cortical artery junction. We trapped the traumatic aneurysm and repositioned a galeal flap. Postoperative CT showed a small infarction in the left frontal lobe. Follow-up angiography two months later showed no residual aneurysm. We suggest that an aggressive surgical intervention be performed whenever TICA is diagnosed.     

Endovascular Treatment of Aneurysms Associated with Fenestrated A1 Segment of Anterior Cerebral Artery: Report of Two Cases

Fenestration in A1 segment of anterior cerebral artery is a rare entity. Treatment of aneurysms derived from a fenestrated artery may be more challenging because the fenestrations provide specific difficulties. A thorough radiologic work‐up driven by high clinical suspicion is needed. Endovascular treatment, although it has been tried only once, ⁷ appears to be the treatment of choice. We successfully treated 2 cases using endovascular techniques and can conclude that endovascular treatment is a safe and effective treatment of aneurysms associated with this rare variation in the A1 segment of 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.     

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.     

大脑前动脉A2段构型对左侧翼点入路夹闭前交通动脉瘤的影响

目的比较左侧优势血供的不同空间构型前交通动脉瘤开颅夹闭手术过程、效果及术中暴露情况,并探讨与之相关的手术适应证。方法回顾性分析山西医科大学第二医院2013年1月-2021年12月连续收治的确诊为左侧优势血供前交通动脉瘤,且进行了动脉瘤开颅夹闭手术的患者资料。根据大脑前动脉A2段的走行方向与冠状面的位置关系,将动脉瘤分为4型：大脑前动脉与冠状面夹角＜22.5°为水平型;大脑前动脉与矢状面夹角＜22.5°为纵向型;右侧大脑前动脉在前且与冠状面夹角112.5°～157.5°为右前左后型;左侧大脑前动脉在前且与冠状面夹角22.5°～67.5°为右后左前型。分别比较水平型组和纵向型组,右前左后型组和右后左前型组间的基线资料、进行左侧翼点入路夹闭手术的时间、夹闭方式（简单夹闭或复杂夹闭）、夹闭效果（是否完全夹闭）、术后3个月和1年动脉瘤是否复发、术后1年GCS评分等指标。结果研究共纳入50例患者,其中水平型8例,纵向型12例,右前左后型16例,右后左前型14例。水平型组与纵向型组各项指标差异均无统计学意义。右前左后型组与右后左前型组术前基线资料差异无统计学意义,右前左后型组的手术时间短于右后左前型组（85.1±19.2?min?vs.?102.1±57.5?min,P=0.032）,2组术后动脉瘤复发率、预后差异无统计学意义。结论右前左后型前交通动脉瘤的手术时间短于右后左前型,但预后方面与右后左前型无显著差异;水平型与纵向型前交通动脉瘤的手术和预后指标无显著差异。     

Ruptured Anterior Spinal Artery Aneurysm: A Case Report

We present a case of a subarachnoid hemorrhage and vasospasm secondary to a ruptured anterior spinal artery aneurysm associated with a Chiari 1 malformation. To our knowledge this is the first reported spinal artery aneurysm with this association.     

Occlusion of the Middle Cerebral Artery Branch Mimicking Aneurysm

A 26-year-old man was admitted to our department due to intermittent left hemiparesis for 3 months. Magnetic resonance image showed subacute infarction in the right precentral gyrus. Digital subtraction angiography and magnetic resonance angiography revealed an aneurysmal protrusion at the right middle cerebral artery (MCA) bifurcation. It was difficult to differentiate the aneurysm from the occlusion of the middle trunk of the MCA trifurcation. Brain single photon emission computerized tomography showed a decrease in perfusion in the right posterior frontal lobe without vascular reserve. Therefore, we planned a superficial temporal artery-MCA anastomosis with an exploration of the right MCA bifurcation. Intraoperatively, the aneurysmal opacification on preoperative angiography proved to be the proximal stump of the occluded middle trunk of the MCA trifurcation. An aneurysmal protrusion at the MCA bifurcation does not always indicate an aneurysm. In diagnosing protruding vascular lesions at the MCA bifurcation, the possibility of a vascular stump should be considered according to their angioanatomical appearance and the history of the patient.     

Three-Dimensional Angiographic Demonstration of Plexiform Fenestrations of the Proximal Anterior Cerebral Artery Associated with a Ruptured Aneurysm

A rare case of ruptured aneurysm associated with multiple A₁ fenestrations resembling plexiform network was demonstrated by 3D angiography. A 56-year-old female presented with a ruptured aneurysm in the A₂ segment of the left distal anterior cerebral artery associated with the right A₁ fenestration. The ruptured aneurysm was occluded with surgical neck clipping via interhemispheric approach without neurological deficit. Plexiform fenestrations of the right distal A₁, opposite side to the left ruptured A₂ aneurysm, were clearly visible on postoperative 3D angiography. Our case may strongly support the theory described by Paget, namely that a remnant of the plexiform anastomosis between the primitive olfactory artery and A₁ segment is the source of such fenestration.     

Revascularization for Symptomatic Occlusion of the Anterior Cerebral Artery Using Superficial Temporal Artery

Isolated symptomatic occlusion of the anterior cerebral artery (ACA) is a rare condition and until date, only few cases regarding the revascularization of the ACA have been reported. This paper reports on successful attempt to revascularize the ACA using superficial temporal artery (STA) in patient with isolated symptomatic occlusion of the ACA. A 69-year-old man presented with several episodes of transient weakness involving left lower extremity. Cerebral angiography showed occlusion of the right ACA at the A2 segment. After medical treatment failure, the patient underwent STA-ACA bypass surgery. Subsequent to surgery, there was immediate disappearance of transient ischemic attack and follow-up angiography showed favorable revascularization of the ACA territory. Bypass surgery can be considered in the patients with symptomatic occlusion of the ACA, who have experienced failure in medical treatment.     

Transbrachial Stent-Assisted Coil Embolization of Right Posterior Inferior Cerebellar Artery Aneurysm: Technical Case Report

OBJECTIVE AND IMPORTANCE: We describe a case of stent-assisted coil embolization of a wide neck right posterior inferior cerebellar artery (PICA) aneurysm via a transbrachial artery approach. CLINICAL PRESENTATION: A 73-year-old woman with a past medical history of hypertension, hyperlipidemia, colon cancer, and osteoporosis presented with a throbbing occipital area headache. Magnetic resonance angiography revealed a wide neck right PICA aneurysm. She presented for a planned endovascular stent-assisted coil embolization. TECHNIQUE: The initial transfemoral approach was complicated by persistent guide catheter instability due to marked tortuosity of the right vertebral artery (VA). The left VA could not be accessed due to left subclavian occlusion with steal syndrome. Neuroform-2 (Boston Scientific; Natick, MA) stent-assisted Matrix (Boston Scientific; Natick, MA) coil embolization was successfully performed through a 6-French guide catheter using a transbrachial approach. CONCLUSION: Current advances in technology produce neuroendovascular devices that are smaller with increased flexibility, allowing nonfemoral vascular access to the cerebral circulation via alternate arterial routes. This patient case demonstrates transbrachial access is a viable approach for endovascular aneurysm coil embolization, with or without stent assistance, in cases with an unstable guide catheter due to tortuous vessels or abnormal anatomy when femoral access is complicated or contraindicated.     

Endovascular Treatment of Aneurysms Arising from the Proximal Segment of the Anterior Cerebral Artery

Objective

Aneurysms arising from the proximal segment of the anterior cerebral artery (A1) are rare and challenging to treat. The aim of this study was to report our experience with endovascular treatment of A1 Aneurysms.

Methods

From August 2007 through May 2012, eleven A1 aneurysms in eleven patients were treated endovascularly. Six aneurysms were unruptured and 5 were ruptured. One patient with an unruptured A1 aneurysm presented with subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. Procedural data, clinical and angiographic results were reviewed retrospectively.

Results

All of the aneurysms were successfully treated with coil embolization. Six were treated with a simple technique while the remaining 5 required adjunctive technique : double catheters (n=2), balloon-assisted (n=2), and stent-assisted (n=1). The immediate angiographic control showed a complete occlusion in all cases. Procedure-related complication occurred in only one patient : parent artery occlusion, which was not clinically significant. All patients had excellent clinical outcomes but one patient was discharged with a slight disability. No neurologic deterioration or bleeding was seen during the follow-up period in this cohort of patients. Follow-up angiography (mean, 20 months) was available in ten patients and revealed stable occlusion in all cases.

Conclusion

Endovascular treatment is a feasible and effective therapeutic modality for A1 aneurysms. Tailored microcatheter shaping and/or adjunctive techniques are necessary for successful aneurysm embolization because of the projection and location of A1 aneurysms.