Aneurysms of the pericallosal-callosomarginal junction

doi:10.1016/0090-3019(84)90199-X

Surgical Neurology

Volume 21, Issue 3, March 1984, Pages 261-266

https://doi.org/10.1016/0090-3019(84)90199-X Get rights and content

Abstract

Aneurysms of the pericallosal-callosomarginal junction are rare and carry a high mortality and morbidity rate. We report a series of 11 cases that were operated upon by one surgeon using modern available methods of treatment. There were six women and five men. Average age was 40.6 years. Only two patients had additional unruptured aneurysms. There was no operative mortality, but the morbidity was formidable (27.3%).

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Cited by (54)

Mini anterior interhemispheric approach for A3 segment distal anterior cerebral artery aneurysms
2023, Clinical Neurology and Neurosurgery
Aneurysms of the A3 segment of the distal anterior cerebral artery (DACA), in relation to the genu of the corpus callosum, are specific sub-group which pose unique surgical challenges due to their discrete anatomical location. We describe a mini-anterior interhemispheric approach which can be safely utilised to clip these aneurysms rather than the traditional bifrontal approach.
Retrospective analysis of the clinical and radiological data of ruptured DACA-A3 aneurysms operated between 2014 and 2021 at our institute. A curvilinear scalp incision within the hairline followed by raising small, unilateral, free frontal bone flap, avoiding the opening of frontal sinus. Superior sagittal sinus is displaced medially, inter-hemispheric dissection carried out with posterior trajectory and small callosotomy is performed. DACA is skeletonised, proximal control is established, and the A3 aneurysm is dissected and clipped.
Our cohort of 18 patients had a definite female preponderance (F:M::2:1) with mean age of 55.6 years. On admission three patients were categorized as WFNS Grade I, thirteen in Grade II, and two in Grade III for subarachnoid haemorrhage. All the patients had evidence of blood in the interhemispheric fissure; intraparenchymal haemorrhage was seen in seven, with intraventricular haemorrhage in six patients. Within the A3 segment six aneurysms were infragenu (inferior), eight were at the genu (anterior) and four were supragenu (superior). Two (11.1%) elderly patients succumbed post-surgery following ischemic infarcts and associated complications. At the time of follow-up at 3 months of the remaining sixteen (72.2%) patients, thirteen had a good outcome (mRS 0–3) and three (16.7%) had a poor outcome (mRS > 3).
The mini anterior interhemispheric is an effective minimally invasive alternative for A3 segments aneurysms and helps to avoid the complications of the conventional bifrontal interhemispheric approach.
Bifrontal Interhemispheric Approach Involving Cutting the Superior Sagittal Sinus for Distal Anterior Cerebral Artery Aneurysms
2019, World Neurosurgery
Citation Excerpt :
DACA aneurysms are located on the A2–A5 segments of the anterior cerebral artery.6 Because most DACA aneurysms arise at the bifurcated region formed by the origin of the callosomarginal artery from the pericallosal artery, they require different microsurgical approaches than aneurysms in A1 segments or anterior communicating artery aneurysms.1,6-8 The unilateral anterior interhemispheric approach, that is, without resection of the superior sagittal sinus (SSS), has been widely used to address these aneurysms.9
The unilateral interhemispheric approach for distal anterior cerebral artery aneurysms presents several risks, such as postoperative venous infarction due to occasional sacrifice of parasagittal bridging vein and postoperative frontal lobe damage due to retraction force. To overcome these risks, we used a bifrontal craniotomy with straight dural incision and cutting of the superior sagittal sinus.
We retrospectively reviewed 61 patients (42 unruptured and 19 ruptured A2 and A3 aneurysms) who under aneurysm clipping through bifrontal interhemispheric approach between March 2007 and December 2017. There were 35 A2 aneurysms and 27 A3 aneurysms, and mean size of aneurysms was 5.45 mm. The modified bifrontal interhemispheric approach involved 3 steps: bifrontal craniotomy of centrobasal portion of the frontal bone, ligation and division of anterior one third of the superior sagittal sinus, and approaching the aneurysm via the interhemispheric space. All patients underwent computed tomography on postoperative days 3 and 7 for evaluation of brain retraction damage or venous infarction.
Among patients with ruptured aneurysms, 79% had a favorable outcome (Glasgow Outcome Scale score 4 or 5) 6 months after primary subarachnoid hemorrhage; all patients with unruptured aneurysms had favorable outcomes. Surgical outcome was strongly related to preoperative neurologic Hunt and Hess grade. Three patients had poor outcomes due to poor Hunt and Hess grade on admission (grade 3 in 2 patients, grade 4 in 1 patient). Follow-up CT showed that venous infarction did not occur in any of the patients.
Modified bifrontal interhemispheric approach may be a safe and effective method for treating A2 and A3 aneurysms with relatively good clinical outcome and no surgery-related complications.
Operative Management of Distal Anterior Cerebral Artery Aneurysms Through a Mini Anterior Interhemispheric Approach
2017, World Neurosurgery
Distal anterior cerebral artery (DACA) aneurysms, also known as pericallosal artery aneurysms, are present in 1.5%–9% of all intracranial aneurysms. Here we characterize the important microsurgical anatomy of DACAs; describe the surgical approach to treating these aneurysms with a minimally invasive surgical technique, the mini anterior interhemispheric approach (MAIA); and examine the nuances of aneurysm clipping in this region.
This was a retrospective and descriptive analysis of a series of aneurysm surgeries performed at the National Institute of Neurology and Neurosurgery in Mexico City. Cadaveric dissections were used to demonstrate relevant cerebrovascular anatomy. We analyzed patient demographic data and aneurysm characteristics. Patients' neurologic grade was evaluated using the Hunt and Kosnik (H-K) scale, and surgical outcomes were evaluated using the Glasgow Outcome Scale (GOS). Other variables were analyzed using the χ² test.
We analyzed a total of 32 DACA aneurysms (10 nonruptured and 22 ruptured), representing 5.8% of all aneurysms. The study cohort was 64.3% females and 35.7% males. H-K grade II was the most frequent classification (32.4%); 42.8% of patients presented with a Fisher grade IV aneurysm. Aneurysm location was classified as supra-genu, genu, or infra-genu. Eight patients had multiple aneurysms, among which 50% were located at the bifurcation of the middle cerebral artery.
Surgical clipping through a MAIA approach is an excellent treatment option for pericallosal artery aneurysms.
Aneurysms of the distal anterior cerebral artery: A clinical series
2011, Neurologia i Neurochirurgia Polska
Distal anterior cerebral artery (DACA) aneurysms, also called pericallosal or A2 aneurysms, are rare and comprise about 1.5 to 9% of all intracranial aneurysms. In this study, a series of 10 patients with DACA aneurysms who were surgically treated in our clinic is presented and discussed, focusing on their clinical features and surgical outcomes.
A total of 344 patients with cerebral aneurysms were operated on in our clinic and 10 patients (2.9%) with DACA aneurysms were studied retrospectively. All patients underwent a computed tomography (CT) scan followed by four-vessel digital subtraction angiography (DSA).
Initial CT revealed intracerebral haematoma (ICH) in 7 patients (70%) and in 2 of them the haematoma was over 3 cm in diameter. The pericallosal-callosomarginal bifurcation was the most common location in 9 patients (90%). Four cases (40%) showed multiple aneurysms. The mean waiting time for the operation was 4.8 days. Surgical clipping was performed in all the cases. Multiple aneurysms required two different craniotomies in the same session. The patients with ICH over 3 cm in diameter, in addition to poor preoperative grade, are likely to have a poor outcome, and so clinical grade is the definite factor affecting the surgical outcome of patients.
DACA aneurysms are usually small and bleeding occurs irrespective of their size because of the lack of resistant arachnoid membranes at the level of the pericallosal cisterns. All DACA aneurysms, even if very small in size or discovered incidentally, should be aggressively treated because of the high tendency to rupture.
Tętniaki tętnicy mózgu przedniej w odcinku dystalnym (distal anterior cerebral artery – DACA), określane również jako tętniaki tętnicy okołospoidłowej lub A2, są rzadkie i stanowią 1,5–9% wszystkich tętniaków śródczaszkowych. W pracy przedstawiono objawy kliniczne i wyniki leczenia chirurgicznego w serii 10 pacjentów z DACA leczonych w ośrodku autorów.
W ośrodku autorów operowano dotąd 344 pacjentów z tętniakami mózgu; przeanalizowano retrospektywnie dane 10 pacjentów (2,9%) z tętniakami DACA. U wszystkich chorych wykonano tomografię komputerową (TK) głowy, a następnie czteronaczyniową cyfrową angiografię subtrakcyjną naczyń mózgowych.
Obecność krwiaka śródmózgowego stwierdzono w pierwszej TK u 7 chorych (70%) – u 2 średnica krwiaka przekraczała 3 cm. Najczęstszą lokalizacją tętniaka było miejsce podziału na tętnicę okołospoidłową i spoidłowo-brzeżną (9 pacjentów, 90%). W 4 przypadkach (40%) stwierdzono tętniaki mnogie. Średni czas do operacji wyniósł 4,8 dnia. We wszystkich przypadkach wykonywano chirurgiczne klipsowanie tętniaka. W przypadkach tętniaków mnogich konieczne było wykonanie drugiej kraniotomii podczas tego samego zabiegu. Większe prawdopodobieństwo niekorzystnego wyniku leczenia dotyczy, oprócz chorych z niekorzystną punktacją kliniczną przed zabiegiem, również pacjentów z krwiakiem śródmózgowym o średnicy > 3 cm. Stopień w ocenie klinicznej jest jednoznacznym czynnikiem określającym wynik leczenia chirurgicznego.
Tętniaki DACA są zwykle małe, a krwawienie pojawia się niezależnie od ich rozmiaru, ze względu na brak stawiających opór błon pajęczynówki na poziomie zbiorników okołospoidłowych. Wszystkie tętniaki DACA, nawet małe lub stwierdzone przypadkowo, powinny być leczone zdecydowanie, ze względu na ich dużą skłonność do pękania.
Clinical features and surgical outcomes of ruptured distal anterior cerebral artery aneurysms in 20 consecutively managed patients
2009, Journal of Clinical Neuroscience
Citation Excerpt :
Therefore, DACA aneurysms require definitive treatment, even if discovered incidentally at a smaller size. Ruptured DACA aneurysms are frequently associated with ICH.4,9,14 In this study, ICH was observed, on admission, in 11/20 (55%) patients.
Optimal surgical management of ruptured aneurysms of the distal anterior cerebral artery continues to provide unique technical challenges. This study presents 20 consecutively managed such patients, with special attention given to the clinical and radiological characteristics, as well as the surgical outcomes. Intracerebral hematoma was seen in 11 of the 20 patients, and intraventricular hemorrhage occurred in 4 (20%). Angiography revealed that 9 (45%) patients had multiple aneurysms. Three patients (15%) had “mirror” distal anterior cerebral arterial aneurysms on the contralateral side. Eleven patients (55%) had aneurysms located at the supracallosal portion of the anterior cerebral artery, while 9 patients (45%) had aneurysms located below the genu of the corpus callosum. The mean aneurysmal diameter was 3.85 mm; 18 aneurysms (90%) were less than 6 mm in diameter. Eighteen patients (90%) underwent a microsurgical procedure; 2 (10%) underwent endovascular coiling due to poor clinical grade. A favorable outcome was achieved in 14 (70%) patients. Advances in microsurgical techniques will be required to further improve clinical outcome.
Endovascular therapy of distal anterior cerebral artery aneurysms-an effective treatment option
2008, Surgical Neurology
Citation Excerpt :
The direct comparison of endovascular with surgical treatment of aneurysms of the PA is difficult because of the heterogeneous nature of surgical therapy. Three neurosurgical studies with medium or small case numbers of 23, 16, and 11 patients [35,41,24] indicate a mortality rate of 0%, whereas the mean mortality from 18 studies including 382 patients before 1998 was 9.7% [17]. This mortality appears to have decreased somewhat since then but still amounts to between 5.5% and 6.9% [25,8].
Surgical treatment of APAs is associated with relatively high morbidity and mortality. The aim of this study was to illustrate the technical achievements of endovascular procedures in the distal anterior cerebral artery area, technical difficulties and how they can be overcome, and the outcome of endovascular treatment of APAs.
Between 1997 and 2006, of 49 patients with APAs at our institution, 29 were treated endovascularly (4.1% of all endovascularly treated aneurysms; F:M = 3.8; mean age, 52.8 ± 11.5 years), and 12 were treated surgically. Twenty-one (72.4%) of the endovascularly treated patients had a subarachnoid hemorrhage. The mean observation period was 25 ± 22.8 months.
In 27 (93.1%) cases, complete occlusion of the aneurysm was achieved. The intervention led to 5 (17.2%) cases of minor complications with no neurologic deficits: 2 thromboembolisms, 1 local thrombus, 1 occlusion, and 1 recurrent hemorrhage. Mortality related to the intervention was 3.4%. There was no morbidity associated with the elective procedures. The dome-to-neck ratio is the main predictor of reperfusion. The most important factor impairing the outcome in terms of the GOS status is the presence of an intraparenchymal hematoma, followed by thrombembolic complications.
Endovascular treatment of APAs is feasible, safe, and effective. Mortality and morbidity are comparable with surgical therapy. An intraparenchymal hematoma has a severe negative influence on the patient's condition after rehabilitation. In these cases, surgical intervention should be considered. In case of incomplete occlusion of the aneurysm, prompt reintervention is required.

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Aneurysms of the pericallosal-callosomarginal junction

Abstract

Distal anterior cerebral artery aneurysm

Neurosurgery

Hypothermia and interruption of carotid, or carotid and vertebral circulation in the surgical management of intracranial aneurysms

J Neurosurg

The anterior cerebral artery and its syndromes

Brain

Intracranial arterial aneurysms

Pericallosal aneurysms

J Neurosurg

Immediate and late results of surgery in cases of saccular intracranial aneurysms

J Neurosurg

Cerebral angiography

Aneurysms of the pericallosal artery