Giant Anterior Communicating Artery Aneurysm Research Articles

Selective clipping of giant anterior communicating artery aneurysms remains a reliable therapeutic option

BackgroundGiant anterior communicating artery (AcomA) aneurysm represent a significant surgical challenge. Our study aimed to discuss the therapeutic strategy in patients with a giant AcomA aneurysm treated by selective neck clipping through a pterional approach. MethodsAmong all operated patients from an intracranial aneurysm between January 2015 and January 2022 (n = 726) in our institution, three patients with a giant AcomA aneurysm treated by neck clipping were included. Early (<7days) outcome was noted. Early postoperative CT scan was performed in all patients to detect any complications. Early DSA was also performed to confirm giant AcomA aneurysm exclusion. The mRS score was recorded 3 months after treatment. The mRS≤ 2 was considered as a good functional outcome. Control DSA was performed one year after treatment. ResultsIn the three patients, after a large frontopterional approach, a selective exclusion of their giant AcomA aneurysm was obtained after a partial pars orbitalis of the inferior frontal gyrus resection. Ischemic lesion was noted in 1 patient and chronic hydrocephalus in 2 patients with ruptured aneurysm. The mRS score after 3 months was good in 2 patients. Long term complete occlusion of the aneurysm were noted in the three patients. ConclusionSelective clipping of a giant AcomA aneurysm is a reliable therapeutic option after a careful evaluation of local vascular anatomy. An adequate surgical exposure is frequently obtained through an enlarged pterional approach with an anterior basifrontal lobe resection, especially in an emergency situation and/or in case of high position of anterior communicating artery.

Commentary: Left Callosomarginal to Right Pericallosal In Situ Bypass, Partial Trapping, and Thrombectomy of a Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Commentary: Left Callosomarginal to Right Pericallosal In Situ Bypass, Partial Trapping, and Thrombectomy of a Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Commentary: Left Callosomarginal to Right Pericallosal In Situ Bypass, Partial Trapping, and Thrombectomy of a Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA Correspondence: Kunal V. Vakharia, MD, Department of Neurosurgery and Brain Repair, University of South FloridaMorsani College of Medicine, 2 Tampa General Circle, Tampa, FL33606, USA. Email: [email protected]

Orbitozygomatic Craniotomy for Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Giant intracranial aneurysms pose a significant surgical challenge because of the associated difficulty in achieving adequate visualization of the parent artery and aneurysm neck. This patient had an incidentally identified giant anterior communicating artery aneurysm. An orbitozygomatic craniotomy was performed for aneurysm exposure and aneurysmal neck dissection. Aneurysm dome opening and thrombectomy was performed to debulk the aneurysmal mass, which facilitated subsequent aneurysmal neck visualization. Sequential utilization of temporary clips of the bilateral A1 and bilateral A2 vessels reduced hemorrhage during thrombectomy. Multiple permanent clips were applied along the dissected aneurysm neck to permit occlusion. A small fracture of the aneurysm neck was identified, and cotton was applied with subsequent tamponade utilizing a fenestrated clip to maintain hemostasis. Indocyanine green fluoroscopy was used to verify parent and distant vessel patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Microsurgical Clip Placement for a Giant Anterior Communicating Artery Aneurysm With Intraluminal Thrombus: 2-Dimensional Operative Video

Giant brain aneurysms account for approximately 5% of all intracranial aneurysms. Although treatment modalities can vary widely, none is ideal for every patient. Endovascular treatment is usually preferred, especially when the large size of the aneurysm limits visualization of the brain parenchyma and parent vessels that arise from the aneurysm, making surgical clip placement across the neck a difficult task. However, despite the higher chances of morbidity, microsurgery is an effective treatment modality due to lower recurrence rates. Surgically, a wide neck, calcifications, or atheroma are complicating factors to be considered while planning the best treatment. Thus, with an appropriate case selection, a favorable outcome is feasible in most cases. Here, we present the case of a 27-yr-old female who presented with a severe headache for 7 mo and 3 mo of progressive left temporal vision loss, which was confirmed by visual field perimetry using the Humphrey visual field analyzer. Magnetic resonance angiography and digital subtraction cerebral angiography showed an anterior communicating artery complex inferiorly and medially oriented aneurysm measuring 25.4×16.5 mm, with a 3 mm neck. It was fed by the right A1, associated with a hypoplastic left A1, incorporating the proximal right and left A2 segments, with an intraluminal thrombus and causing mass effect on the optic chiasm and hypothalamus. This video demonstrates the microsurgical steps required to perform this operation, through a right orbitozygomatic craniotomy. At a 3-mo follow-up, the patient was neurological intact without complaints. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Anterior communicating artery aneurysm presenting with vision loss

Anterior communicating artery aneurysm rarely presents with symptoms of compression of anterior visual pathways. We report a case of 65 years old man, who had complete loss of vision in right eye and temporal hemianopsia in left eye due to giant anterior communicating artery aneurysm.

Surgical Strategies for Fusiform A2 and Giant Anterior Communicating Artery Aneurysms

usiform aneurysms (FAs) are circumferential lesions of an entire vessel segment and are difficult to treat, espeF cially compared with their saccular counterparts. Although saccular aneurysms are generally accepted as treatable by direct clipping or coil embolization, there is ongoing debate about which therapy is best suited for FAs. Depending on aneurysm location and specific preference of the treating neurovascular center, FAs are usually treated by endovascular stent placement (with growing emphasis on flow diverters), proximal occlusion alone (endovascular or surgical), or cerebrovascular bypass surgery in combination with proximal or distal aneurysm occlusion (1, 2).

The Y-shaped double-barrel bypass in the treatment of large and giant anterior communicating artery aneurysms

Large and giant anterior communicating artery (ACoA) aneurysms usually show partial thrombosis and incorporate both the A(1) and A(2) segments and crucial perforating vessels. Therefore, direct clip placement or endovascular strategies often fail, leaving cerebral bypass surgery as a relevant therapeutic option. The authors present 3 cases in which a giant or large ACoA aneurysm was successfully occluded using a new technique that applies a double-barrel radial artery bypass. A radial artery graft is modified into a Y-shaped double-barrel conduit. After both pterional and parasagittal craniotomies are carried out, the graft is tunneled between both sites and anastomosed in an end-to-side fashion proximally to either a superficial temporal artery (STA) or M(2) branch and distally to bilateral A(3) branches. Aneurysm occlusion is then conducted through the pterional or parasagittal craniotomy. In one case, a 42-year-old patient in whom an endovascular approach had failed, the authors performed an STA-A(3)-A(3) bypass and proximal aneurysm occlusion. In two others, a 49-year-old man in whom coiling had failed and a 56-year-old man in whom a giant ACoA aneurysm was partially thrombosed, the authors performed an M(2)-A(3)-A(3) double-barrel bypass followed by either proximal or distal aneurysm occlusion. Complete aneurysm occlusion with excellent bypass perfusion was documented in the first two cases. In the third case, the authors observed good bypass perfusion with persistent antegrade aneurysm filling, and thus endovascular coil embolization was added to completely occlude the aneurysm. The Y-shaped double-barrel bypass using a radial artery graft allows for safe and effective occlusion of large and giant ACoA aneurysms that cannot be treated by direct clip application.

A giant anterior communicating artery aneurysm associated with hypoplasia of the unilateral internal carotid artery

●Abstract● Objective: There have been few reports on the association of large or giant aneurysms with congenital absence or hypoplasia of the internal carotid artery (ICA). We present a case of a giant anterior communicating artery aneurysm associated with hypoplasia of the unilateral ICA with secondary occlusion. Case presentation: A 62-year-old man was diagnosed with a giant anterior communicating artery aneurysm (10×12×28 mm) associated with hypoplasia of the unilateral ICA. A left common carotid angiogram revealed occlusion of the cervical portion of the left ICA. A right internal carotid arteriogram showed the aneurysm. Both the left anterior cerebral artery and left middle cerebral artery were filled from the right ICA via the anterior communicating artery. Due to the complicated morphology and calcified wall of the aneurysm, we performed endovascular treatment using a combination of 18- and 10-series microcatheters to make separate coil frames in the aneurysmal sac. Twenty-seven Guglielmi detachable coils with a total length of 419cm were placed in the aneurysm, which resulted in satisfactory occlusion. The patient was discharged without complications, and there was no evidence of aneurysmal recurrence for three years. Conclusion: Large or giant aneurysms associated with congenital absence or hypoplasia of the ICA are rare. In their treatment them, it is important to avoid a decrease in collateral blood flow. The endovascular procedure is a reasonable therapeutic option.

Revascularization of the Anterior Cerebral Artery with an A3–A3 Anastomosis and a Superficial Temporal Artery Bypass Using an A3-Radial Artery Graft to Trap a Giant Anterior Communicating Artery Aneurysm: Technical Case Report

How to manage the distal anterior cerebral artery (ACA) circulation in the treatment of a giant anterior communicating artery aneurysm or a giant azygous A2 aneurysm is still controversial. We are reporting the case of a 70-year-old man who presented with an evolving giant thrombosed anterior communicating artery aneurysm. He was successfully treated by trapping the aneurysm in conjunction with an A3-A3 side-to-side anastomosis and a superficial temporal artery bypass using an A3-radial artery graft. The postoperative angiography showed an excellent filling of all the bilateral distal ACA area through the bypass. In cases in which direct clipping to preserve distal ACA flow is quite difficult, the bilateral ACA revascularization described here should be considered as another possibility.

Neck-bridge device for combined endovascular and surgical treatment of a giant anterior communicating artery aneurysm

We report the case of a 58-year-old man with a giant partially thrombosed anterior communicating artery aneurysm, which presented with mass effect. Our treatment strategy consisted of endovascular aneurysm circulatory exclusion prior to surgical resection. To do so, we first occluded both the two A1 segments and the aneurysm neck with a neck-bridge device to prevent further coil migration within the aneurysm sac. Five days later, the aneurysm was surgically removed.

Clinical presentation and management of giant anterior communicating artery region aneurysms.

The authors reviewed their 20-year experience with giant anterior communicating artery aneurysms to correlate aneurysm size with clinical presentation and to analyze treatment methods. In 18 patients, visual and cognitive impairment were quantitated and clinical outcome was categorized according to the Rankin scale. Statistical analysis was performed using Fisher's exact test. At least 3.5 cm of aneurysm mass effect was required to produce dementia in the patient (p = 0.0004). Dementia was usually caused by direct brain compression by the aneurysm rather than by hydrocephalus. Optic apparatus compression occurred with smaller aneurysms (2.7-3.2 cm) when they pointed inferiorly. Aneurysm neck clipping was possible in half of the cases. Special techniques, including temporary clipping, evacuation of intraluminal thrombus, tandem and/or fenestrated clipping, and clip reconstruction were often required. Occlusion of or injury to the anterior cerebral artery (ACA) was the main cause of poor outcome or death. Proximal ACA occlusion, even of dominant A1 segments with small or no contralateral A1 artery, was an effective treatment alternative and was well tolerated as a result of excellent leptomeningeal collateral circulation.

Endovascular occlusion of intracranial vessels for curative treatment of unclippable aneurysms: report of 16 cases

Among 121 intracerebral aneurysms presenting at one institution between 1984 and 1989, 16 were treated by endovascular means. All 16 lesions were intradural and intracranial, and had failed either surgical or endovascular attempts at selective exclusion with parent vessel preservation. The lesions included four giant middle cerebral artery (MCA) aneurysms, one giant anterior communicating artery aneurysm, six giant posterior cerebral artery aneurysms, one posterior inferior cerebellar artery aneurysm, one giant mid-basilar artery aneurysm, two giant fusiform basilar artery aneurysms, and one dissecting vertebral artery aneurysm. One of the 16 patients failed an MCA test occlusion and was approached surgically after attempted endovascular selective occlusion. Treatment involved pretreatment evaluation of cerebral blood flow followed by a preliminary parent vessel test occlusion under neuroleptic analgesia with vigilant neurological monitoring. If the test occlusion was tolerated, it was immediately followed by permanent occlusion of the parent vessel with either detachable or nondetachable balloon or coils. The follow-up period ranged from 1 to 8 years. Excellent outcomes were obtained in 12 cases with complete angiographic obliteration of the aneurysm and no new neurological deficits and/or improvement of the preembolization symptoms. Four patients died: two related to the procedure, one secondary to rupture of another untreated aneurysm, and the fourth from a postoperative MCA thrombosis after having failed endovascular test occlusion. The angiographic, clinical, and cerebral blood flow criteria for occlusion tolerance are discussed.