Kissing aneurysms of the distal anterior cerebral artery

Clipping of Kissing Distal Anterior Cerebral Artery Aneurysms: The Importance of Microsurgical Techniques to Enlarge the Surgical Corridor and Prevent a Premature Aneurysm Rupture

Intracranial kissing aneurysms, arising either from the same artery or from 2 adjacent arteries at similar locations, are rare.1,2 The internal carotid artery is most frequently involved; kissing aneurysms rarely affect the distal anterior cerebral artery (DACA). By dint of the close proximity of the aneurysm fundus, these aneurysms can pose unique operative challenges.3,4 A highly fragile aneurysm dome with a high intraoperative rupture rate is a unique management challenge in DACA aneurysms.5 The stakes are higher when there is an aneurysm rupture in the setting of kissing DACA aneurysms requiring an anterior interhemispheric approach. The negotiation of a tight interhemispheric fissure in between the bridging veins and prevention of a premature aneurysm rupture at a narrow space become vital in these situations. Video 1 highlights the surgical steps of clipping bilateral kissing DACA aneurysms in a 60-year-old woman. This surgical video highlights the microneurosurgical nuances of opening a tense interhemispheric fissure and maneuvers for prevention of a premature aneurysm rupture. These nuances are quintessential in the successful surgical clipping of kissing DACA aneurysms. The patient in Video 1 presented with an acute subarachnoid hemorrhage with severe headache of sudden onset and nuchal rigidity (World Federation of Neurological Surgeons grade II). Both aneurysms were located at the A3-A4 junction and successfully clipped through a right-sided anterior interhemispheric approach. She made a satisfactory postoperative recovery (modified Rankin Scale score of 1 at 6-week follow-up and 0 at 6-month follow-up) with an excellent angiographic outcome.

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.

Kissing Aneurysms: Radiological and Surgical Difficulties in 30 Operated Cases and a Proposed Classification

OBJECTIVE

The first aim of this study is to bring up the radiological and surgical difficulties of kissing aneurysms and to present solutions. The second aim is to develop a classification that can help to predict the difficulties encountered during surgery.

METHODS

The records of 817 patients who were operated on for aneurysm were reviewed retrospectively to identify kissing aneurysms. The radiological and clinical databases of these patients were evaluated in detail.

RESULTS

Kissing aneurysms were detected in 30 patients (3.6%). Radiologically correct diagnosis rate of kissing aneurysms was 80% throughout the series. The most common locations were the anterior communicating artery (12 cases, 40%) and the middle cerebral artery (12 cases, 40.0%). The ruptured aneurysm could not be detected preoperatively in 24% of the patients. Intraoperative rupture occurred in 4 patients (13.3%). Accompanying vascular anomaly/variation was seen in 16 patients (53.3%). As detailed in the text, kissing aneurysms were divided into 3 types according to their position with each other on the parent artery from the surgeon's point of view during surgery: type I (proximal/distal), type II (superior/inferior), and type III (right/left).

CONCLUSIONS

Despite advanced angiographic techniques, even today, kissing aneurysms can be misinterpreted as a single bilobular aneurysm. The ruptured aneurysm may not be detectable preoperatively. These complex aneurysms have a high intraoperative rupture risk. Accompanying vascular anomalies are more common than expected. Clip selection and sequencing are important. Proposed classification helps the surgeon to be aware of intraoperative difficulties that he/she may encounter in advance.

Safety and Efficacy of Bilateral Flow Diversion for Treatment of Anterior Circulation Cerebral Aneurysms

BACKGROUND

Nearly 20% of individuals with an aneurysm will have multiple aneurysms-these individuals are at increased risk of subarachnoid hemorrhage. Treatment of bilateral aneurysms with flow diverters (FDs), or Pipeline embolization device, has not yet been established as an effective therapy. We evaluated the safety and efficacy of a 2-stage treatment of bilateral aneurysms with Pipeline embolization devices placed 6 months apart.

METHODS

We performed a retrospective review to analyze the clinical and angiographic outcomes of 16 individuals with bilateral aneurysms treated with 2-stage flow diversion at a tertiary referral center from January 2010 to July 2018.

RESULTS

Of the 16 patients with 33 aneurysms treated with bilateral flow diversion, 1 had 2 aneurysms treated with a single FD on the contralateral side. The aneurysms treated were ophthalmic, superior hypophyseal, posterior communicating, or cavernous segment aneurysms, with an average size of 6.5 mm. No major complications, such as in-stent stenosis, thromboembolic events, distal intraparenchymal hemorrhage, rerupture, stent migration, or neurological death, were recorded. All the patients had good functional outcomes. At the 24-month follow-up examination, 81% of aneurysms showed complete occlusion. No aneurysm required repeat treatment.

CONCLUSIONS

The results from the present study have demonstrated that 2-stage treatment of bilateral aneurysms with FDs is both safe and efficacious. The timing of contralateral FD stent placement is critical. We found that 6 months allows for adequate neurological recovery and stent endothelialization.

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.