Distal anterior cerebral artery aneurysms

doi:10.1016/S0090-3019(99)00066-X

Surgical Neurology

Volume 52, Issue 2, August 1999, Pages 128-136

https://doi.org/10.1016/S0090-3019(99)00066-X Get rights and content

Abstract

Background

The incidence of saccular aneurysms in the distal anterior cerebral artery (DACA aneurysms), also called pericallosal or A2 aneurysms, has been estimated to be from 1.5 to 9.0% of all intracranial aneurysms in large series in the literature 5, 10, 12, 18. All reported series of DACA aneurysms have shown a high association with intracranial aneurysms in other locations. These aneurysms are fragile, frequently rupture prematurely during exposure, and have a higher morbidity than expected from their angiographic appearance and location.

Methods

A total of 1,350 patients with cerebral aneurysms were operated in the Department of Neurosurgery at Santa Casa Hospital in Belo Horizonte from January 1982 to January 1998. Seventy-two of those 1,350 patients had DACA aneurysms (5.3%), 51 female and 21 male. The age ranged from 26 to 69 years, the mean age being 44 years. This group of patients is reported herein.

We propose three different approaches to DACA aneurysms depending on their location, all of them performed through a unilateral triangular bone flap that can then vary from fronto-basal to parietal.

Results

There was no mortality among patients with a single DACA aneurysm. Five deaths in this series were cases of multiple aneurysms. In patients with preoperative Hunt and Kosnick grades I and II [9], we had 90% good results. In grade III patients, we achieved 68.4% good results. The only grade IV patient had a full recovery. All 74 DACA aneurysms in the 72 operated patients were completely clipped, including two giant aneurysms.

Conclusion

DACA aneurysms have higher morbidity and mortality rates when compared to other supratentorial aneurysms. We recommend the use of a unilateral interhemispheric approach as the most appropriate for aneurysms in this location.

In cases of patients with multiple aneurysms who require two different craniotomies, we propose two surgical stages, starting with the aneurysm that has bled. A high mortality rate was noted when two craniotomies were performed in the same sitting.

Section snippets

Clinical materials and methods

A total of 1,350 patients with cerebral aneurysms were operated by the senior author (AAS) from January 1982 to January 1998. Seventy-two of those 1,350 patients presented DACA aneurysms (5.3%), 51 being female and 21 male. The age ranged from 26 to 69 years, the mean age being 44 years.

The symptom in 65 patients was subarachnoid hemorrhage (90%). Five other patients had seizures (6.9%) and two DACA aneurysms were incidental findings in patients with headache. A total of 122 aneurysms were

Surgical approach

We used three different approaches to DACA aneurysms depending on their location. In order to choose the most appropriate approach, we used the aneurysm angiographic location in the lateral projection. Aneurysms located between the anterior communicating artery (ACoA) and the genu of the corpus callosum are approached differently from those located at or just distal to the genu of the corpus callosum. On the other hand, the latter are approached differently from those more distal in the body of

Results

The results can be seen in Table 1, Table 2, Table 3, Table 4. There was no mortality in cases of patients with a single DACA aneurysm. In patients with preoperative Hunt and Kosnick grades I and II [9], we had 90% good results. In the 19 grade III patients, this rate was 68.4%, and the only grade IV patient had a full recovery. All 74 DACA aneurysms in the 72 operated patients were completely clipped, including two giant aneurysms (Figure 6). This was confirmed by routine postoperative

Discussion

The average incidence of DACA aneurysms is 4.4% in the reviewed literature 2, 3, 5, 6, 12, 13, 16, 21, 27, 31, 34, 35. In our series, this incidence was 5.3%. The multiplicity of aneurysms associated with DACA aneurysms 7, 12, 21, 31, 34 can be confirmed by our series with a percentage as high as 44.4%. We had two patients with bilateral DACA aneurysms and one patient with two aneurysms on the same DACA.

DACA aneurysms are usually small 4, 7, 21, 27, 33. In our series, we found 41 aneurysms

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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.
Contralateral transradial access for coil embolization of distal anterior cerebral artery aneurysm associated with a steep ipsilateral A1-A2 angle
2022, Journal of Stroke and Cerebrovascular Diseases
Endovascular treatment of distal anterior cerebral artery aneurysms is commonly addressed via the ipsilateral A1 segment of the anterior cerebral artery. However, when the parent pericallosal artery has a sharp ipsilateral A1-A2 angle, catheterization through the ipsilateral A1 segment can potentially result in vessel injury, catheter kinking, and/or compromised/stagnant anterior cerebral artery flow. Here, we present a case of a distal anterior cerebral artery aneurysm associated with a steep ipsilateral A1-A2 angle treated with contralateral transradial coil embolization.
A 91-year-old woman presented with a ruptured left distal anterior cerebral artery aneurysm at the A3 segment. The parent pericallosal artery had a steep ipsilateral A1-A2 angle. To safely achieve coil embolization of the aneurysm, a contralateral transradial system via the right A1 segment was employed. Although a secondary ipsilateral transradial system was required for contrast injection, aneurysm obliteration was successfully achieved without vessel injury or system instability.
The A1-A2 angle can be a key anatomical factor in the endovascular treatment of distal anterior cerebral artery aneurysms. The contralateral transradial system is a useful treatment option for distal anterior cerebral artery aneurysms associated with sharp ipsilateral A1-A2 angles. However, if the distal anterior cerebral artery aneurysm cannot be clearly visualized through the contralateral system, an ipsilateral system will be required for contrast injection.
Wedge Resection of the Falx to Clip a Distal Anterior Cerebral Artery Aneurysm
2020, World Neurosurgery
The unilateral anterior interhemispheric approach has been widely used for distal anterior cerebral artery (DACA) aneurysms. However, there are some drawbacks of this approach because of the narrow operative field, including possible brain traction injury, bridging vein injury, and inadequate exposure of the aneurysm. Here, we report a case of a DACA aneurysm covered by the falx that could not be totally exposed with the unilateral interhemispheric approach. We successfully obtained a wide view with wedge resection of the falx, avoiding excessive brain traction and division of the superior sagittal sinus.
A 76-year-old woman with a 6-mm unruptured DACA aneurysm underwent a unilateral craniotomy with the anterior interhemispheric approach. In the operative field, the aneurysm was found at the midline, just below the falx. The aneurysm was covered by the falx and could not be completely exposed with the usual brain retraction. Therefore, we performed wedge resection of the falx, thus obtaining sufficient surgical field and totally exposing the aneurysm. We were then able to apply the clip successfully. Postoperative brain computed tomography angiography showed no remnant aneurysm sac or complications of falx resection or brain retraction, such as bleeding or vessel injury.
When an aneurysm is located just below the falx and is exposed inadequately, performing wedge resection of the falx can expose the aneurysms adequately for application of the clip.
Parent Artery Occlusion for Treatment of a Traumatic Pericallosal Artery Aneurysm: Case Report and Review of the Literature
2020, World Neurosurgery
Traumatic intracranial aneurysms are rare complications after head trauma. This report describes the case of a patient with a traumatic pericallosal aneurysm.
A 73-year-old man developed headache and lower limb paresis, and emergency computed tomography scan revealed a hematoma in the corpus callosum. We performed coil embolization for a pericallosal aneurysm, but follow-up angiography showed recurrence of the aneurysm 6 days after the surgery. We diagnosed this as a traumatic aneurysm and subsequently performed parent artery occlusion without any complications.
We performed parent artery occlusion for a traumatic aneurysm of the pericallosal artery without complications. Pericallosal aneurysms are rare, but we must consider them when encountering a delayed hematoma around the corpus callosum.
Endovascular treatment of distal anterior cerebral artery aneurysms: Long-term results
2020, Journal of Neuroradiology
Endovascular therapy is the first-line therapeutic option for intracranial aneurysms, however the results of the endovascular approach for distal anterior cerebral artery (DACA) aneurysms are not well-known. We assessed the immediate and long-term clinical and angiographic outcomes after endovascular coiling of DACA aneurysms.
We performed a retrospective analysis of all consecutive DACA aneurysms treated by endovascular coiling. Procedural complications, clinical, and angiographic results were prospectively recorded in an institutional aneurysm database between 1992 and 2013.
Satisfactory initial occlusion was achieved for 85.9% of cases (79/92). There were three cases of intraprocedural rupture of the aneurysmal sac and three treatment failures, all involving small aneurysms (< 4 mm). Rates of procedure-related mortality and morbidity were respectively 1.1% and 0%. Scores of 5 (good recovery) or 4 (moderate disability) on the Glasgow Outcome Scale, indicating favorable outcome, were observed for 79.3% of patients (73/92) at hospital discharge. In follow-up, 13 cases of recanalization were observed, 12 of which were classified as major. Ten of the recanalizations underwent a complementary intervention.
The endovascular management of DACA aneurysms appears to be efficacious and safe, although certain technical difficulties may emerge when aneurysms are small. A higher proportion of major recanalization events may imply a more frequent deployment of complementary interventions in comparison to aneurysms situated elsewhere.
Lessons Learned from Endovascular Coil Embolization of Pericallosal Artery Aneurysms and Adoption of Flow Diversion: A Retrospective Cohort Assessment of the Efficacy of Coiling and Flow Diversion
2019, World Neurosurgery
Citation Excerpt :
In the International Subarachnoid Aneurysm Trial (ISAT), PAAs represented 4.4% of ruptured aneurysms.3 Historically, microsurgical repair has been used more frequently than endovascular techniques1,6-13 due to their distal location, small caliber of the parent artery, and the small size of the aneurysmal sac presenting a challenge to the endovascular approach. However, the scenario has changed in the last few years with the introduction of softer and more trackable microcatheters, more advanced coils, as well as newer balloons and stents for aneurysm neck remodeling.14,15
The adoption of endovascular techniques for treatment of pericallosal artery aneurysms (PAAs) has been comparatively gradual due to anatomic and technological factors. We conducted a retrospective cohort study to evaluate the outcomes of PAA treatment with coiling and flow diversion at our institution.
This was a retrospective study of patients treated endovascularly for PAAs from December 2007 to January 2019.
In total, 33 patients with 34 aneurysms were included (25 aneurysms ruptured, 9 unruptured or recurrent). Of the ruptured group, 22 were coiled (88%) and rest treated with flow diversion. Initial angiographic follow up rate was 72%, at median of 159 days. Overall recurrence rate was 40% (10/25) at median of 376 days, all among coiled aneurysms. 6 recurrent aneurysms were retreated with further coiling (2) and flow diversion (4). Of the unruptured/recurrent group, 5 were coiled (55%) and remainder treated with flow diversion. Angiographic follow-up rate was 100% at median of 267 days. Recurrence rate was 22% (2/9), both in coiled aneurysms. Overall, 27 aneurysms were coiled, 9 treated with flow diversion and 3 with “partial” flow diversion. All aneurysms treated with pipeline flow diversion achieved 100% occlusion. No re-rupture or new rupture was observed. Good clinical outcome (modified Rankin Scale 0–2) was seen in 79% of patients.
Our study demonstrates that endovascular coiling for PAAs is associated with a definite rate of recurrence, which has to be monitored with timely angiography. We also demonstrate the excellent effectiveness of flow diversion for PAAs with either presentation.

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Vascular: AneurysmDistal anterior cerebral artery aneurysms

Abstract

Section snippets

Clinical materials and methods

Surgical approach

Results

Discussion

Surg Neurol

Clin Radiol

Surg Neurol

Studies of arteries of the brain. II. The anterior cerebral arterysome anatomic features and their clinical implications

Neurology (NY)