Letter to the editor: multimodal treatment of co-existent callosal cavernous malformation and anterior communicating artery aneurysm associated with an infraoptic anterior cerebral artery

Abstract

Dear Sir, We wish to bring to your attention the neuroradiological findings in a 40-year-old woman who presented with a sentinel headache. Neuroimaging revealed a hemorrhagic cavernous malformation in the body of the corpus callosum and an anterior communicating artery (ACoA) aneurysm (Fig. 1a and b). Aneurysmal subarachnoid hemorrhage was excluded on the basis of computed tomography and lumbar puncture. The aneurysm measured 1.2 cm on a catheterbased angiogram; an early carotid bifurcation at the level of the ophthalmic artery (OA) origin and a horizontal course of the right A1 segment (the only A1) were also noted (Fig. 2a and b). Given the higher risk of rupture of the aneurysm, the patient underwent coil embolization of the aneurysm. The patient did well, but significant aneurysm recurrence was documented on the follow-up angiogram. She underwent microsurgical clipping through a right-sided transsylvian approach. Intraoperatively, the right A1 was seen to originate from the carotid artery at the level of the OA, coursing beneath the optic nerve to supply the ACoA aneurysm (Fig. 3). Intraoperative indocyanine green fluorescence angiography (Fig. 4) and postoperative conventional angiography revealed total aneurysm occlusion. To our knowledge, the present report is the first case of an infraoptic anterior cerebral artery (ACA) in association with a cavernous malformation. This is also the first reported case of multimodal treatment of an infraoptic ACoA aneurysm variant. The origin of an infraoptic ACA remains speculative. Enlargement of the prechiasmal arterial plexus, persistence and enlargement of an anastomotic loop between the primitive dorsal and ventral OAs and persistence of a fetal anastomosis between the primitive maxillary artery, and the ACA have all been implicated [1–3]. The aberrant anastomosis often leads to agenesis of ipsilateral and contralateral A1 segments [4]. Infraoptic ACAs are classified according to local vascular anatomy [5]. The type I configuration has a normal ACoA complex with an additional infraoptic vessel P. Kan : P. Yashar :A. J. Chamczuk : E. I. Levy : L. N. Hopkins : A. H. Siddiqui (*) Department of Neurosurgery, University at Buffalo, State University of New York, 3 Gates Circle, Buffalo, NY 14209, USA e-mail: asiddiqui@ubns.com