Ruptured fusiform aneurysm of the proximal anterior cerebral artery (A1 segment)

Clip Reconstruction of Fusiform A1 Segment Aneurysm Using Lateral Supraorbital Approach

Fusiform aneurysms of the anterior cerebral artery are a surgical rarity encountered only occasionally by a neurosurgeon.1,2 Seen most commonly in the vertebrobasilar territory, these aneurysms differ in pathophysiology and clinical presentation from their saccular counterparts. Arterial dissections and atherosclerosis are the leading causes of these aneurysms in young and elderly patients, respectively.3 Patients can present with symptoms related to mass effect/compression of adjacent structures or with ischemic symptoms apart from aneurysm rupture. Management of these aneurysms remains challenging owing to the lack of a distinct neck. Surgical options include clip reconstruction, parent vessel occlusion, or aneurysm trapping with4 and without1 bypass using a branch of the superficial temporal artery. Clipping techniques used for these aneurysms include the use of fenestrated clips, vessel wall reconstruction, and wrapping.5,6 However, due to enormous variations in aneurysm morphology, each case presents a unique challenge; hence neurosurgeons need to be aware of this important entity. Endovascular techniques including parent vessel occlusion or vessel-preserving techniques using coil or flow diverters have also been described,3 but clipping remains the preferred choice for most surgeons worldwide. In Video 1, we present a case of fusiform A1 segment aneurysm in a 34-year-old gentleman and demonstrate how the aneurysm was clipped using a lateral supraorbital approach. He made an uneventful recovery with subtle right lower limb weakness. This video shows the technique and utility of a minimally invasive skull base approach for dealing with a fusiform anterior circulation aneurysm.

Fusiform aneurysms of anterior cerebral artery: center experience and systematic literature review

Fusiform aneurysms of the anterior cerebral artery (ACA) are uncommon, and the natural history of this entity is poorly characterized. Along with our center experience, we conducted a systematic literature review to help shed light on the clinical course of ACA fusiform aneurysms. We queried our institutional database to identify cases with fusiform aneurysms of ACA. In addition, following the PRISMA algorithm, we identified all reported cases published in the English literature from the inception of PubMed until December 2022. We categorized clinical presentations into three categories: (i) traumatic/iatrogenic, (ii) spontaneous symptomatic ruptured/unruptured, and (iii) spontaneous asymptomatic aneurysms. We utilized descriptive statistics. We identified seven cases from our center along with 235 patients from published literature. Blunt trauma was responsible for the development of 19 aneurysms. Sixty-three percent of these aneurysms tend to rupture within 2 weeks from the initial trauma, and despite treatment, only 74% of these patients had good clinical outcomes. Spontaneous symptomatic presentation occurred in 207 patients and was often associated with previous/concomitant ACA dissection. Subarachnoid hemorrhage from ruptured aneurysms was the most common presentation. Spontaneous symptomatic fusiform aneurysm is rapidly evolving lesions, and treatment is necessary. Three of our own cases were treated with an endovascular flow diverter (pipeline) stenting with good outcomes. Spontaneous asymptomatic aneurysms were reported in nine patients. These lesions are often associated with other vascular abnormalities. Treatment included surgical clipping with good clinical outcomes. Instead, four patients from our center database were managed conservatively with equally good outcomes. Our study demonstrates good clinical outcomes when fusiform aneurysms of ACA, especially when symptomatic, are treated promptly with either reconstructive or deconstructive therapies.

The spectrum of venous anomalies associated with atretic parietal cephaloceles: A literature review

Background:

Parietal atretic cephalocele (PAC) is a small, subscalp lesion with underlying extracranial meningeal, neural, and glial tissues. In this paper, we analyze the related literature on the continuum of PAC-associated venous anomalies and report an exemplary case.

Methods:

The PubMed Medline database was searched using the following search algorithm: (Atretic encephalocele) OR (Rudimentary meningocele,) OR (Atypical meningocele) OR (Meningocele manqué) OR (Meningeal heterotopia). Only papers detailing the venous anomalies associated with PACs have been included.

Results:

A total of 30 papers in our search documented PAC-associated venous abnormalities. The overall number of cases reported was 68 (including our exemplary case). The most frequently identified associated venous anomaly was the presence of a “fenestrated superior sagittal sinus” recorded in 48.5% of cases (n = 33), followed closely by “persistent falcine sinus” in 47% (n = 32) and vertical embryonic positioning of the straight sinus (SS) in 44% (n = 30). The complete absence of a SS was reported in 39.7% (n = 27) and various anomalies of the Galenic system were reported in 26.8% of cases (n = 12).

Conclusion:

Although benign in nature, PACs are often a marker for the presence of complex and variable cerebral venous malformations, requiring extensive preoperative imaging workup for both the superficial and deep venous systems to obtain an accurate understanding of the anatomy of the venous system and guide surgical planning.

Endovascular treatment for aneurysms at the A1 segment of the anterior cerebral artery: current difficulties and solutions

Aneurysms located at the A1 segment of the anterior cerebral artery are considered rare and unique entities. Endovascular treatment (EVT) is effective in preventing aneurysmal bleeding. However, EVT for A1 aneurysms is difficult due to their distinctive configurations. A current review of EVT for A1 aneurysms is lacking. Therefore, we focused on the available literature on this specific issue. To more clearly expound this entity, we also provided some illustrative cases. The A1 segment can be equally divided into the proximal, middle, and distal segments. Proximal aneurysms are most common and difficult to treat via EVT. The A1 segment has a complex anatomy and many important branches. Due to the small size, predominant posterior direction, and sharp upturn of the microcatheter from the parent artery, microcatheter positioning and support is difficult for A1 aneurysms. EVT for A1 aneurysms mainly includes reconstructive and deconstructive strategies. The complications of EVT for A1 aneurysms include aneurysmal perforation, thromboembolic events, and coil protrusion related to stent-assisted embolization. A1 aneurysms represent rare and difficult vascular lesions. EVT is quite challenging for A1 aneurysms due to their distinctive configurations. The outcomes are acceptable.

Successful microsurgical clipping of ruptured fusiform aneurysm of the anterior cerebral artery. Case report and review of the literature

BACKGROUND

Fusiform aneurysms (FA) of the anterior cerebral artery (ACA) are found rarely. The common clinical presentation is a subarachnoid hemorrhage (SAH). Surgery is the main treatment to prevent rebleeding.

CASE DESCRIPTION

The authors present a case report of the ruptured FA of the ACA. The presented case demonstrates the successful microsurgical clipping of the fusiform ACA aneurysm.

CONCLUSION

A1-segment FA can lead to SAH with poor prognosis. The main goal of surgical treatment is to prevent rebleeding. Direct microsurgical clipping is one of the surgical options.

The Special Considerations in the Surgical Management of Proximal Anterior Cerebral Artery Aneurysms

BACKGROUND

Proximal anterior cerebral artery (A1) aneurysms are difficult to clip because of their frequent proximity to perforators, location behind the parent artery, or adherence to surrounding structures.

METHODS

We retrospectively reviewed a consecutive series of patients with A1 aneurysms and report the clinical status, radiologic findings, treatment methods, and outcome.

RESULTS

This series included 19 male and 12 female patients with a mean age of 50 years. The morphology of the A1 aneurysms was fusiform in 2 patients and saccular in the remaining 29 patients. Multiple aneurysms were presented in 9 patients (29.0%). On admission, 26 patients (83.9%) presented with subarachnoid hemorrhage, 3 of whom had an additional intracerebral hematoma. All surgeries were performed with a standard pteriomal craniotomy. The mean Glasgow Outcome Scale score at final follow-up was 4.8 (interquartile range, 5, 5), with 26 patients (83.9%) rated as 5. The mean follow-up time was 38.5 months (range, 12-60 months).

CONCLUSIONS

A1 aneurysms are rare but have their own complex characteristics and are difficult to treat. Meticulous analysis of the relevant angiographs is needed for their diagnosis. An important consideration in surgery is the preservation of perforators and prevention of rupture. Wide opening of the sylvian fissure and temporary control of the parent artery can facilitate dissection of the A1 aneurysms dome. Multiple intraoperative monitoring methods, such as microvascular Doppler ultrasonography and somatosensory and motor evoked potential monitoring, can reduce the relevant complications of surgery.

Mid A1 blister aneurysm presenting with subarachnoid hemorrhage: Case report and review

Blister aneurysms are uncommon and difficult-to-treat lesions. They are a substantial cause of morbidity and mortality when encountered. Here, we report a blister aneurysm of the mid A1 segment of the anterior cerebral artery presenting with diffuse basal subarachnoid hemorrhage (SAH). The aneurysm was treated by surgical clipping of the parent vessel. Postoperatively, there was no filling of the parent vessel or aneurysm. A treatment algorithm including direct surgical repair and flow diversion for ruptured blister aneurysms is described. A high level of suspicion should be maintained in the setting of angiographic-negative SAH with an asymmetrically diffuse pattern.

Endovascular treatment of A1 aneurysms. A series of five cases with a brief literature review

Aneurysms of the A1 segment of the anterior cerebral artery are rare and represent less than 1% of intracranial aneurysms. There are few reports available in the literature describing the role of endovascular management of these rare aneurysms. In the present series we describe five patients with A1 aneurysms presenting at our institution with various clinical presentations, treated successfully by endovascular method with a good clinical outcome. From January 2008 to July 2011, five patients (two males and three females) with A1 aneurysms were treated by endovascular means. Four of the patients presented with subarachnoid hemorrhage due to rupture of the A1 aneurysm and one patient presented with symptoms of mass effect in the form of headache and ophthalmoplegia. The age group ranges from eight to 52 years with a mean age of 34.2 years. Four of the patients were treated by coiling without any assisted technique whereas one patient who had a dissecting fusiform aneurysm was treated with stent-assisted coiling. Technical success was achieved in all the patients.We did not encounter any procedure-related complications in any of our cases. All the patients had an uneventful course with good clinical outcome. Angiographic follow-up was available in four patients (80%). Endovascular treatment of this rare group of aneurysms is an effective and safe treatment modality, however large series are required to support our findings.

Stent-assisted coil trapping in a manual internal carotid artery compression test for the treatment of a fusiform dissecting aneurysm

Internal carotid artery (ICA) trapping can be used for the treatment of giant intracranial aneurysms, blood blister-like aneurysms, and fusiform dissecting aneurysms. Fusiform dissecting aneurysms are challenging to treat surgically and endovascularly because of no definite neck and critical perforators. Surgical or endovascular trapping of the ICA with or without an extracranial-intracranial bypass has commonly been used as an effective method to treat these lesions, but balloon test occlusion (BTO) must be performed. Here, we report a case of a ruptured fusiform dissecting aneurysm of the distal ICA, which was successfully treated using an endovascular ICA trapping with a manual ICA compression test instead of BTO.

Endovascular parent artery occlusion for the treatment of wide-neck A1 segment aneurysms: a single-center experience

The goal of this study was to evaluate the feasibility and efficacy of A1 occlusion at the level of wide necked A1 aneurysms, where there are bilateral patent A1 segments and a patent AcomA. Between 2000 and 2010, 9 patients with wide necked A1 aneurysms were treated by coiling of the aneurysm along with parent vessel occlusion. All aneurysms had a wide neck (≥ 4 mm). None were treated in the acute phase of a subarachnoid hemorrhage. Three small infarcts were noted on routine post-treatment head CT, 1 of which was symptomatic (transient hemiparesthesia). On control angiogram at 6 months or more, 3 A1 recanalizations were found, 2 of which had a stable small neck recurrence. None of the aneurysms ruptured on follow-up. In this series, parent artery occlusion was effective in treating wide-necked aneurysms arising from the A1 segment in patients with adequate collateral supply.

Fusiform Aneurysm of the Anterior Communicating Artery Treated by Vascular Reconstruction

OBJECTIVE

Fusiform aneurysm of the anterior cerebral artery is rare and difficult to treat because of perforators. We encountered a patient with subarachnoid hemorrhage due to rupture of a fusiform aneurysm of the anterior communicating artery complex, and treated this patient with cerebral revascularization.

CASE PRESENTATION

A 39-year-old man presented with sudden severe headache resulting from subarachnoid hemorrhage. Digital subtraction angiography showed dilatation from the distal A1 segment to the proximal A2 segment of the left anterior cerebral artery. Despite intensive conservative treatment, repetitive angiography showed aneurysmal growth from this dilated portion.

INTERVENTION

Proximal clipping and clip-on wrapping on the A2 segment was successfully performed with a A3-A3 bypass. He was discharged without neurological deficit.

CONCLUSION

Cerebral revascularization technique is necessary to achieved appropriate obliteration without ischemic complications.