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Case Reports
. 2018 Mar 21:9:67.
doi: 10.4103/sni.sni_4_18. eCollection 2018.

A difficult-to-treat Acom aneurysm with the combined vascular anomaly of Acom fenestration and accessory anterior cerebral artery

Hideyuki Tomita  1 , Katsuya Saito  1
Affiliations
Case Reports

A difficult-to-treat Acom aneurysm with the combined vascular anomaly of Acom fenestration and accessory anterior cerebral artery

Hideyuki Tomita et al. Surg Neurol Int. .

Abstract

Background: Vascular anomaly and aneurysmal formation of an anterior communicating artery (Acom) complex has often been reported. Because of such a complicated relationship between the vascular structure and aneurysms, Acom aneurysm is one of the most difficult aneurysms to treat among other common anterior circulation aneurysms. We experienced an extremely rare and difficult-to-treat case of ruptured Acom aneurysm with the combined vascular anomaly of the Acom fenestration and an accessory anterior cerebral artery (ACA).

Case description: A 29-year-old man underwent a clipping surgery for a ruptured Acom aneurysm with an Acom fenestration and an accessory ACA. By reasons of the complicated Acom structure and a posteriorly-projecting aneurysm, the patient was operated via an interhemispheric approach, which is generally reported to provide the best operative view for all types of Acom aneurysms. However, we could not help applying a clip in the narrow working space and the limited operative view, due to the poor mobilization of Acom complex and the interruption by an accessory ACA.

Conclusion: The interhemispheric approach may exceptionally have a blind area behind the Acom complex in the case of Acom aneurysms with an accessory ACA. Additionally, the aneurysms arising from the Acom fenestration strongly require neurosurgeons to take a more accurate surgical approach to obtain a direct visualization for an aneurysmal neck.

Keywords: Acom fenestration; accessory anterior cerebral artery; interhemispheric approach; pterional approach; subarachnoid hemorrhage.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
(a) Head computed tomography (CT) on admission. Diffuse subarachnoid hemorrhage in the basal cistern. In particular, a thick subarachnoid hemorrhage in the proximal portion of interhemispheric fissure. (b) Three-dimensional-CT Angiography (3D-CTA) on admission. 3D-CTA showed the anterior communicating artery (Acom) fenestration, but no evidence of aneurysm. The quality of this study was poor, probably due to high intracranial pressure
Figure 2
Figure 2
(a-d) Three-dimensional-digital subtraction angiography (3D-DSA) on admission. (a) water's view, (b) A-P view, (c) L-R view, (d) magnification picture of c. 3D-DSA revealed the vascular anomaly [the anterior communicating artery (Acom) fenestration and an accessory anterior cerebral artery] and small Acom aneurysm projecting posteriorly. An accessory anterior cerebral artery (arrow head) arose from the upper limb of the fenestrated segment. In contrast, the Acom aneurysm (arrow) arose from the inferior limb of the fenestrated segment. (e-f) Intraoperative photographs. The surgical view obtained from the interhemispheric approach showed a blind area behind the Acom complex with limited mobilization. A fenestrated clip was applied to be able to preserve an accessory anterior cerebral artery
Figure 3
Figure 3
(a) Head computed tomography (CT) on Day 13. The focal subarachnoid hemorrhage was observed around the aneurysmal clip, suggesting the re-rupture from the remnant of anterior communicating artery (Acom) aneurysm. (b-c) Two-dimensional-digital subtraction angiography (2D-DSA) after re-rupture. b: P-A view, c: R-L view. 2D-DSA showed the recurrence of Acom aneurysm. (d) Three-dimensional-digital subtraction angiography (3D-DSA) after re-rupture, posterior view with caudal angulation. The recurrence of an aneurysm (arrow) was observed next to the clip
See this image and copyright information in PMC

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