Kissing aneurysms of distal anterior cerebral arteries demonstrated by magnetic resonance angiography

Endovascular Treatment of Intracranial Kissing Aneurysms: Technical Feasibility and Clinical Outcomes

BACKGROUND

Kissing aneurysms are situated on the same artery but have separate points of origin. Open surgical strategies for access from opposing directions may be technically problematic. Recent advances in protective devices and coiling techniques have compelled the present study, aimed at technical aspects and procedural outcomes of coil embolization in this setting.

METHODS

Data prospectively accruing between May 2001 and May 2020 were systematically reviewed, assessing clinical and morphologic outcomes of coil embolization in 36 patients with 72 kissing aneurysms.

RESULTS

Lesions most often involved paraclinoid internal carotid artery (n = 22), followed by anterior communicating artery (n = 7). Single-stage coil embolization of both aneurysms took place in nearly all patients (n = 35). Microcatheter tips for selecting paired aneurysms were usually directed opposite to one another (32 of 36, 88.9%), applying protective devices (i.e., balloons or stents) to 1 or both aneurysms in 21 patients (58.3%). Balloons were placed in 9 patients, often when treating first aneurysms and largely for second aneurysms as well (7 of 9, 77.8%). Stents deployed in 14 patients involved first and second aneurysms equally. Two patients required balloon of stent combinations. No procedure-related morbidity or mortality resulted. In follow-up of 68 aneurysms (mean: 40.2 ± 28.1 months) after coiling, 86.8% (59 of 68) showed sustained complete saccular occlusion.

CONCLUSIONS

Strategies for endovascular treatment of kissing aneurysms rely heavily on characteristics that the paired aneurysms display. Properly conducted single-stage coil embolization is a safe and effective method of treating such lesions.

Mirror Distal Anterior Cerebral Artery Aneurysms in a Patient with Subarachnoid Hemorrhage

BACKGROUND

Mirror distal anterior cerebral artery aneurysms (DACAAs) are a rare finding in patients with subarachnoid hemorrhage, with only a few cases reported.

CASE DESCRIPTION

A 40-year-old man was admitted for sudden-onset headache, nausea and vomiting, and transient right arm hypoesthesia. Computed tomography scan showed a subarachnoid hemorrhage with intracerebral hemorrhage within the interhemispheric fissure, but computed tomography angiography failed to identify any aneurysms. Subsequent digital subtraction angiography with three-dimensional reconstructions revealed 1.5-mm-diameter mirror DACAAs on the A3 segments. However, the definite rupture site remained unidentifiable. After interdisciplinary consultation, endovascular treatment was favored, and complete occlusion of both DACAAs was achieved by coiling without stent placement. During coiling of the right DACAA, a thrombus in the right callosomarginal artery formed, and treatment with abciximab (ReoPro) was initiated to dissolve the thrombus. After treatment, the patient presented with right leg paresis; however, computed tomography did not show any ischemia, intracerebral hemorrhage increase, or vasospasm. Over the following days, the leg paresis improved, and the patient achieved increased mobilization. He was transferred for further rehabilitation 16 days after hemorrhage. The leg paresis had recovered to a grade 3/5.

CONCLUSIONS

Rapid identification of the rupture site in patients with subarachnoid hemorrhage and multiple aneurysms is crucial for initiating optimal treatment. In patients with mirror aneurysms in close proximity to each other, this is not easily accomplished, complicating treatment decisions. Although clipping has been the standard for DACAA occlusion, coiling should be taken into consideration as a viable alternative.

Mirror image of bilateral DACA aneurysm with its successful surgical management

Background:

Among various locations of intracranial aneurysms reported in the literature, two different aneurysms situated symmetrically opposite on bilateral distal anterior cerebral arteries (DACA) are very rare.

Case Description:

Here, we report a rare case of mirror image distal anterior cerebral aneurysm in a middle-aged male patient. The patient presented with severe headache and loss of consciousness. Angiography was done which suggested mirror imaging of two aneurysms located over both DACA. It was treated through microsurgical approach with a successful outcome.

Conclusion:

Careful analysis of intracranial vasculature should be done using angiography, particularly in different views and stages to rule out multiple aneurysms at different locations in the same artery or at different arteries. Mirror images of bilateral DACA aneurysms are very rare. Fundamental surgical strategy of securing the parent artery and clipping the neck after meticulous dissection should be followed.

Kissing aneurysms of the distal anterior cerebral artery: A case report and literature review

Intracranial 'kissing' aneurysms are rare types of multiple aneurysms referring to two adjacent aneurysms arising from identical or different arteries with separate origins and partially adherent walls. The present study reported a 54-year-old female patient, who was identified with a 'kissing' aneurysm in the A3 segment of the bilateral anterior cerebral arteries, as demonstrated by head computed tomography and emergency cerebral digital subtraction angiography analysis. In total, 12 days following the clipping of the aneurysms, the patient was discharged with a Modified Rankin Scale=0 and recovered well with no neurological deficits. Based on previous literature, it was indicated that the majority of patients with 'kissing' aneurysm have a good prognosis and the cure rate is as high as 96.8%. However, the recovery rate may not be that high as the sample size is not large enough to thoroughly demonstrate the complete prognosis of 'kissing' aneurysms.

Three distal anterior cerebral artery aneurysms in the same branch associated with five additional intracranial aneurysms

Background:

Multiple distal anterior cerebral artery (DACA) aneurysms appear as rare findings. Simultaneous treatment of such lesions can be particularly challenging. A report of three aneurysms on the same parent artery has not been reported before. We report a case of three DACA aneurysms treated within one microsurgical operation in a patient with eight aneurysms.

Case Description:

A 62-year-old woman incidentally presented with multiple various size saccular aneurysms, including tree on the left DACA. One of the DACA aneurysm was located on the A3 segment, and the other two were on the A4 and A5 segments. Ligation of all three of these aneurysms was planned in one operation. A standard anterior interhemispheric approach was utilized. Three aneurysms were successfully clipped using four clips. Intraoperative angiography confirmed aneurysm occlusion with parent artery patency preservation. The patient showed no new postoperative neurological deficit.

Conclusion:

Clipping multiple DACA aneurysms within a single microneurosurgical operation is a feasible treatment option. Meticulous analysis of preoperative imaging features is crucial for selecting the best, patient-specific treatment strategy.

Mirror image distal anterior cerebral artery aneurysms treated with coil embolization. a report of two cases and literature review

Mirror image aneurysms of the distal anterior cerebral arteries (DACA) are rare. To the best of our knowledge this is the first case report of two patients with mirror image DACA aneurysms treated successfully with coil embolization. The association of aneurysms with anatomic variants has been extensively reported. We may speculate that the remnants of the failed regression of the supreme anterior communicating artery could lead to an increase in stress across their territorial bifurcation, leading to the development of mirror image DACA aneurysms. We found the endovascular treatment of mirror image DACA aneurysms to be feasible and effective. If possible, we suggest the treatment of both aneurysms in one procedure.

Endovascular treatment of "kissing aneurysms" at the anterior communicating artery

Kissing aneurysms are the rare type of multiple aneurysms. They are adjacent aneurysms of different origin arteries in the same region, which require great care in diagnosis and treatment. We report a case of kissing aneurysms at the anterior communicating artery (AcomA) which were treated by endovascular coil embolization.

Endovascular management for bilateral ophthalmic segment "kissing" aneurysms presenting with nasal bleeding. A case report

A rare case of bilateral ophthalmic segment "kissing" aneurysms is reported. A 32-year-old man presented with nasal bleeding and headaches. Cerebral angiography demonstrated bilateral internal carotid-ophthalmic aneurysms. Both aneurysms were treated in the same procedure because of uncertainty over which aneurysm had bled. The left aneurysm was coiled intrasaccularly, the right one was treated by parent artery occlusion. Surgery for kissing aneurysms has been recognized as hazardous and challenging. We emphasize that the endovascular technique described is reasonable.

Multiple mirror-like intracranial aneurysms. Report of a case and review of the literature

While multiple intracranial arterial aneurysms occur in 26.4% of patients with aneurysms, in our practice bilateral mirror-like aneurysms are encountered in 9.4% of patients. Multiple mirror aneurysms in the same patient are exceedingly rare. We report a case of mirror-like middle cerebral artery aneurysms associated with mirror-like posterior inferior cerebellar arteries aneurysms and discuss their significance. Although an exceptional finding, multiple mirror-like aneurysms may shed light on the vulnerability of different arterial segments to specific diseases.

A neurosurgical view of anatomical variations of the distal anterior cerebral artery: an anatomical study

Object

The vascularization pattern of the anatomy of the distal anterior cerebral artery (ACA) remains a subject of debate. The authors provide detailed information about the distal ACA and shed light on issues concerning it that have not previously been adequately discussed.

Methods

Fifty adult human brains (100 hemispheres) were obtained during routine autopsies. Cerebral arteries were separately cannulated and injected with latex. The vascularization patterns of the cortical branches and the variations of the arteries were investigated. The authors found that the distal ACA supplied all the inner surfaces of the frontal and parietal lobes and a median of one third of the outer surfaces. The origin of the arteries from the main trunk and their exit angles affected the vascularization patterns of the hemispheres. The authors redefine controversial terminology regarding the callosomarginal artery.

Conclusions

In each hemisphere, the vascularization pattern of the distal ACA is different to a greater or lesser extent. An awareness of this fact will contribute significantly to surgical interventions.

Kissing Aneurysms at the Junction of the Internal Carotid Artery and the Ipsilateral Duplicate Anterior Choroidal Arteries-Case Report-

A 45-year-old woman presented with kissing aneurysms located at the junctions of the internal carotid artery and the duplicate anterior choroidal arteries manifesting as acute subarachnoid hemorrhage. The aneurysms were clipped during temporary occlusion of the internal carotid artery. Surgery for kissing aneurysms requires special consideration including analysis of the anatomical relationship before clipping, control of premature rupture during clipping, and preservation of the patency of the two anterior choroidal arteries after clipping.

Distal Anterior Cerebral Artery Mirror Aneurysms and Middle Cerebral Artery Aneurysms-Case Report-

A 52-year-old woman presented with bilateral distal anterior cerebral artery (ACA) mirror aneurysms, in addition to two right middle cerebral artery (MCA) aneurysms. The left distal ACA and right MCA aneurysms were clipped through right interhemispheric and right pterional craniotomies. The right distal ACA aneurysm was thrombosed. Distal ACA aneurysms tend to be multiple, but mirror aneurysms are rare, especially in the absence of congenital vascular anomaly. Single stage unilateral craniotomy is recommended for surgical treatment.

Distal Anterior Cerebral Artery Aneurysms-Report of 26 Cases-

Distal anterior cerebral artery (ACA) aneurysms are rare, and constitute approximately 1.5% to 9% of all intracranial aneurysms. They show some unique features compared with other aneurysms in the cerebral circulation and are frequently treated with a different technique. Twenty-six of 364 patients with cerebral aneurysms treated at our department between 1996 and 2004 had distal ACA aneurysms (7.1%). Twenty-three of the 26 patients were treated through an anterior interhemispheric approach and two with a pterional approach. All saccular aneurysms were successfully clipped except one which was embolized after the surgery. The only fusiform aneurysm spontaneously thrombosed and resolved with parent artery occlusion. Two of the 26 patients had multiple aneurysms. The surgical mortality was 8%. Distal ACA aneurysms have higher mortality and morbidity than other anterior circulation aneurysms. They should be aggressively treated even if very small because of the tendency to rupture. Endovascular treatment is an alternative in the management of these aneurysms. The most important factors affecting the outcome are grade on admission and the neurosurgeon's experience.

“Kissing Aneurysms” of the Anterior Communicating Artery Treated With Coil Embolization

PURPOSE

To present a case of kissing aneurysms of the anterior communicating artery treated with endovascular coil embolization and discuss the advantages and disadvantages of this technique compared with neck clipping.

CASE REPORT

A 48-year-old man became drowsy and was admitted to the hospital; he had right hemiparesis and aphasia. Computed tomography revealed diffuse subarachnoid hemorrhage; diagnostic angiography identified an aneurysm at the left A1-A2 junction of the anterior communicating artery and another in the distal anterior cerebral artery (ACA). Endovascular coil embolization was performed on the same day. During the procedure, the 3-mm-diameter junctional aneurysm was successfully packed with coils, but an additional aneurysm was suspected; right carotid angiography following embolization of the left aneurysm clearly showed a mirror image aneurysm of the right A1-A2 junction. The right aneurysm was treated using the same technique. The broad-necked ACA aneurysm was unsuitable for embolization, so neck clipping was performed 5 weeks later. The patient was discharged to his home following complete recovery 7 weeks after the coil embolization.

CONCLUSIONS

Kissing aneurysms are a rare and specific type of multiple aneurysms that require caution in diagnosis and surgical management. Endovascular treatment may be suitable because it does not involve dissection around the aneurysms.

Giant aneurysm of the azygos pericallosal artery: case report and review of the literature

BACKGROUND

Pericallosal aneurysms are encountered less than 6.7%, and giant aneurysms among them even less. Giant azygos pericallosal artery aneurysm at the callosomarginal bifurcation is extremely rare, and our case presented herein is the second one. The case is discussed with thorough review of the literature.

METHODS

A 65-year-old woman presented with an extremely rare giant aneurysm on the azygos pericallosal artery manifesting as subarachnoid hemorrhage in World Federation of Neurosurgical Societies Grade 3. Computed tomography (CT), magnetic resonance angiography (MRA), and four vessel angiography revealed a giant azygos pericallosal artery aneurysm associated with a second aneurysm at the left M1.

RESULTS

After recovery to Grade 2, she underwent surgery via the right frontal interhemispheric approach for the azygos artery aneurysm on the 17th day after bleeding. The true dimensions of the aneurysm were greater than indicated by angiography because of partial thrombosis. Trilobulate aneurysm was carefully dissected from the surrounding structures. Postoperative cerebral angiography showed no filling of the clipped aneurysm and preservation of circulation.

CONCLUSIONS

The treatment of distal anterior cerebral artery aneurysms is often difficult, because of their broad-based irregular configurations and adherence to surrounding tissue, tendency to bleed irrespective of size and the coexistence of other cerebral aneurysms. However, excellent outcomes can be obtained based on thorough preoperative radiologic evaluation, including magnetic resonance imaging (MRI), and correct selection of surgical approach.

Bilateral ophthalmic segment "kissing" aneurysms presenting with subarachnoid hemorrhage--case report

A 31-year-old woman presented with bilateral ophthalmic segment "kissing" aneurysms causing subarachnoid hemorrhage manifesting as sudden severe headache and nausea 3 days before admission. Cerebral angiography demonstrated bilateral internal carotid-superior hypophyseal artery aneurysms, both projecting medially from the medial surface of the internal carotid arteries and appearing to touch each other. Both aneurysms had to be clipped in the same operation, because of uncertainty over which aneurysm had bled. She underwent bilateral frontotemporal craniotomy on the day after admission. Intraoperatively, the two aneurysms were in contact with each other in the suprasellar cistern. Each aneurysm was clipped through the ipsilateral approach without any incident. The patient returned home a month after the operation and has since resumed her previous work. Identification of this rare entity of bilateral ophthalmic segment "kissing" aneurysms is important for surgical planning. Closely situated, bilateral ophthalmic segment aneurysms require a modified surgical strategy for proximal arterial control and the approach to each aneurysm.

Kissing mirror image anterior communicating artery aneurysms--case report

A 45-year-old male presented with an extremely rare case of symmetrical kissing aneurysms located at the both ends of the anterior communicating artery. Angiography and three-dimensional computed tomography (3D-CT) angiography clearly showed the relationship of the kissing aneurysms. The aneurysms were clipped through the right pterional approach. Temporary clipping of the anterior cerebral arteries for 5 minutes was required to gain enough operative space. The patient was discharged without neurological deficits. 3D-CT angiography, magnetic resonance angiography, or rotatory digital subtraction angiography may be useful for detecting kissing aneurysms, but the most important issue is awareness of this unusual condition.

"Kissing" bilateral large carotid-ophthalmic aneurysms. A case report

A case of unruptured bilateral large carotid-ophthalmic aneurysms, which appear to be adjoining and "kissing" each other when visualized by three-dimensional computed tomographic angiography (3-D CTA), is reported. Although bilateral carotid-ophthalmic aneurysms are not rare, bilateral large ones are quite rare, and direct imaging of "kissing aneurysms" of this portion has not been reported. Since 3-D CTA is becoming a useful tool for the diagnosis of cerebral aneurysms, we propose that these and similar bilateral large carotid-ophthalmic aneurysms are good candidates for the term "kissing aneurysms".