Traumatic Aneurysm of the Callosomarginal Artery-Cortical Artery Junction from Penetrating Injury by Scissors

Traumatic intracranial aneurysms (TICAs) are rare and are associated with high rates of morbidity and mortality. TICAs usually result from head injuries caused by traffic accidents, industrial accidents, or gunshots. We report a traumatic aneurysm of the callosomarginal artery-cortical artery junction arising from a penetrating injury by scissors. A 51-year-old woman was admitted to our hospital after suffering a penetrating injury caused by scissors. Computed tomography (CT) and CT-angiography demonstrated a right orbital roof fracture, subarachnoid hemorrhage, frontal lobe hemorrhage, intraventricular hemorrhage, and a traumatic aneurysm of the right callosomarginal artery-cortical artery junction. We trapped the traumatic aneurysm and repositioned a galeal flap. Postoperative CT showed a small infarction in the left frontal lobe. Follow-up angiography two months later showed no residual aneurysm. We suggest that an aggressive surgical intervention be performed whenever TICA is diagnosed.

Endovascular Coil Embolization of Distal Anterior Cerebral Artery Aneurysms: Angiographic and Clinical Follow-up Results / 신경중재치료의학

PURPOSE: This study is an overview of the clinical and angiographic outcomes of patients who undergo treatment for distal anterior cerebral artery aneurysms. MATERIALS AND METHODS: Between January 2009 and March 2012, 444 cerebral aneurysms were treated using endovascular coil embolization at our institute. Among them, 217 aneurysms were followed-up with angiography at least six months later. Of these, there were 16 distal anterior cerebral artery (ACA) aneurysms in 16 patients. We conducted a retrospective review of clinical and radiological follow-up results of all patients with distal ACA aneurysms. The clinical and angiographic outcomes were assessed using the modified Rankin scale (mRS) and the Raymond classification scale, respectively. RESULTS: The mean age was 54.7 +/- 10.2 years (41-75 years). The mean follow-up period was 20.6 +/- 9.64 months (6-37 months). Three patients presented with acute rupture. The average aneurysm size was 4.98 +/- 1.39 mm (3.0-8.1 mm), and eight of 16 aneurysms (50%) had aspect ratios < 2.0. All 16 patients presented with complete obliteration immediately after the procedure. However, two patients had procedure-related complications, one with coil extrusion to the subarachnoid space without hemorrhage and one with thromboembolism subsequent to chemical thrombolysis. In the follow-up angiography, one major and five minor recurrences (for a total of six recurrences, 37.5%) were detected. However, the differences between the ACA aneurysm group and others were not statistically significant. Clinical outcomes were good for all of the patients at the time of discharge (mean mRS: 0.25, 0 to 1) and at the follow-ups (mean mRS: 0). CONCLUSION: Despite a comparatively high recurrence rate, the endovascular treatment of distal anterior cerebral aneurysms is feasible and has a good clinical outcome.

Surgical Treatment of Giant Serpentine Aneurysm of A2-A3 Segment Distal Anterior Cerebral Artery : Technical Case Report

OBJECTIVE: To report our surgical experience using in situ end-to-side bypass for giant serpentine distal anterior cerebral artery aneurysm, unsuitable for microsurgical clipping. METHODS: A 49-year-old woman presented with headache and intermittent loss of consciousness. The brain computed tomography scan revealed a partially calcified mass in the interhemispheric fissure. On cerebral angiography, that was giant (30x18 mm sized), serpentine aneurysm originating from the A2 to A3 segment of the distal anterior cerebral artery (DACA). The aneurysm was trapped with clips, and the right A3 segment to left A3 segment of DACA, end-to-side in situ bypass was performed. Surgical result was favorable, with no newly developed ischemic event in the acute recovery period. Postoperative angiography showed total occlusion of the aneurysm and good patency, with preserved distal flow. CONCLUSION: Giant fusiform aneurysms of the DACA are extremely rare and can be particularly challenging to treat. End-to-side A3 : A3 bypass with aneurysm trapping could be a treatment modality for these locations.

Endovascular or Microsurgical Treatment of Ruptured Distal Anterior Cerebral Artery Aneurysms: Clinical Outcomes and Technical Considerations / 대한뇌혈관외과학회지

OBJECTIVE: To analyze the clinical characteristics and outcomes of ruptured distal anterior cerebral artery (DACA) aneurysms and to discuss optimal treatment strategy. METHODS: Out of 488 patients with ruptured intracranial aneurysms, 24 were treated for DACA aneurysms between February 2001 and January 2009. The medical records, radiological data and outpatient clinic charts of these patients were retrospectively reviewed. RESULTS: The 24 patients (6 men, 18 women) had a mean age of 52 years (range, 30-70). Among the 24 patients, 6 underwent coiling and 17 underwent clipping. Fifteen patients had a Hunt-Hess grade of II, 5 with III, 3 with IV and 1 had a grade of V. Nine patients had a Fisher grade of II, 1 with III and 14 had a grade of IV. Twenty-one (88%) patients had a good clinical course after treatment with endovascular (5 of 6 patients, 83%) or surgical (16 of 18 patients, 89%) treatments. Nineteen of 20 patients (95%) with good preoperative states (Hunt-Hess grade I-III) and 2 of the 4 patients (50%) with poor preoperative states (Hunt-Hess grade IV and V) demonstrated good clinical outcomes with Glasgow Outcome Scale (GOS) scores of 4-5. Two patients (8%) died due to pneumonia or preoperative severe brain damage. CONCLUSIONS: Acceptable and favorable outcomes were achieved in patients with good preoperative states who were treated with either clipping or coiling of ruptured DACA aneurysms. Immediate and active treatment should be mandatory for favorable outcomes.

Effects of Concomitant Intracerebral Hemorrhage on Patient Outcomes in Ruptured Distal Anterior Cerebral Artery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: In this study, we analyzed the results of treating ruptured distal anterior cerebral artery (DACA) aneurysms surgically and reported the DACA aneurysms' characteristics and the influence of concomitant intracerebral hemorrhage (ICH) on the outcome. METHODS: We retrospectively analyzed 24 patients with DACA aneurysms from among 430 patients who had received a diagnosis of, and undergone operations for, intracranial aneurysms in our hospital, from January 2003 to December 2008. We analyzed their age, gender, initial Glasgow coma scale (GCS) on admission, Hunt and Hess grading scale, and past medical history of hypertension or diabetes. We used computed tomography angiography (CTA) scans to investigate the location, size, multiplicity, ICH, and volume of each aneurysm and scored its surgical outcome according to the Glasgow Outcome Scale (GOS). RESULTS: The 24 patients (8 men and 16 women) with DACA aneurysms were aged 5-73 years (mean, 52 years), and 6 had multiple aneurysms. Eleven patients had concomitant ICH, and these patients' mean hematoma volume was 15.2 cc. There were 4 patients with GCS scores from 14 to 15 and 7 patients with GCS scores below 13. Nine patients had GOS scores from 4 to 5, 1 patient had a GOS score of 3, and 1 patient, a GOS score of 1. Fisher's exact test revealed that initial GCS (P=0.03) and Hunt and Hess grade affected surgical outcomes. Concomitant ICH was not a statistically significant factor (P=0.7). CONCLUSIONS: We found DACA aneurysms were more common in women, multiple cerebral aneurysms were frequent, and these aneurysms were not large. Clinical outcomes were associated with initial GCS and Hunt and Hess grades. ICH was more frequent in DACA aneurysms, and ICH showed no correlation with either the clinical course or the final surgical outcome.

Clinical Features of Distal Anterior Cerebral Artery Aneurysms Based on 26 Consecutive Cases / 대한뇌혈관외과학회지

OBJECTIVE: Distal anterior cerebral artery (DACA) aneurysms are relatively uncommon, and operative management is usually difficult because of narrow operative fields, deep exposure, interhemispheric adhesions, and problems in achieving proximal vessel control. We present our experience with 26 DACA aneurysm cases and analyze the clinical features and surgical outcomes retrospectively. METHODS: From 1998 to 2008, surgical clipping of DACA aneurysms was carried out in 26 patients among a total of 504 patients with intracranial aneurysms. In each case, the clinical and radiological features were carefully reviewed through angiograms, medical records, and intraoperative findings. RESULTS: The most common location of DACA aneurysms was the junction of the pericallosal and callosomarginal arteries: 23 occurred at pericallosal-callosomarginal (PC-CM) junctions while three occurred in the pericallosal-frontopolar (PC-FP) region. Multiple aneurysms were found in 15 cases (58%), and associated vascular anomalies were noted in three cases (12%). Eleven (64.7%) of the 17 ruptured aneurysms and seven (77.8%) of the nine unruptured aneurysms were smaller than 7 mm; only two aneurysms (7.7%) were larger than 10 mm. Seven cases (26.9%) underwent minor premature rupture with proximal artery control. CONCLUSION: Despite the small patient group, our data suggest that in general, DACA aneurysms tend to rupture at a smaller size than do intracranial aneurysms. Thus, unruptured DACA aneurysms require aggressive treatment, even when they are small.

Characteristics and Surgical Outcomes of Distal Anterior Cerebral Artery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Distal anterior cerebral artery (dACA) aneurysms are uncommon, and they require special treatment because of the narrow exposure in the interhemispheric fissures, the dense adhesions between the cingulate gyri and their association with multiple aneurysms or traumatic pseudoaneurysm. The aim of this study was to assess the characteristics and surgical outcomes of dACA aneurysms. METHODS: Among the 520 cases of cerebral aneurysms that were operated on from 1997 to April 2007, we experienced 31 cases of dACA aneurysms that developed in 30 patients. The medical records and radiological findings were retrospectively reviewed. RESULTS: The clinical characteristics of the patients with dACA aneurysms included the following. (1) The incidence of the dACA aneurysm was 5.9% of the total 520 cases, and the dACA aneurysms displayed a female predominance. (2) The most common location of the dACA aneurysms was the junction of the pericallosal and callosomarginal arteries. (3) Multiple aneurysms were found in 12 patients (40%), and the most concomitantly found aneurysm was MCA aneurysm. (4) The larger aneurysms more than 10 mm size all had thrombus in the sac, and their angiographic findings were underestimated compared with their findings on the operative fields. (5) dACA aneurysms shows frequent intracerebral hemorrhage (ICH) and subdural hemorrhage on the initial brain CT scan (28.5%). They also had a higher rate of intraoperative rupture (12.9%) than the rupture rate for the aneurysm at other locations (7.9%). (6) Traumatic pseudoaneurysms on the dACA were observed in two cases, and one of these cases showed massive ICH shortly after head trauma. (7) Twenty-six out of 30 patients (86.7%) showed a good outcome with a mortality rate of 3.3%. CONCLUSIONS: The dACA aneurysms are uncommon and they have unique characteristics compared to intracerebral aneurysms at other sites. Especially, a very careful surgical approach must be used for dACA aneurysms because they have a higher rate of intraoperative rupture. Yet the surgical outcome for dACA patients was good for the ruptured or unruptured aneurysm cases in our study. Therefore, dACA aneurysms have to be treated with considering their special characteristics.

Surgical Experience of the Ruptured Distal Anterior Cerebral Artery Aneurysms

OBJECTIVE: Distal anterior cerebral artery (DACA) aneurysms are fragile and known to have high risks for intraoperative premature rupture and a relatively high associated morbidity. To improve surgical outcomes of DACA aneurysms, we reviewed our surgical strategy and its results postoperatively. METHODS: A total of 845 patients with ruptured cerebral aneurysms were operated in our hospital from January 1991 to December 2005. Twenty-three of 845 patients had ruptured DACA aneurysms which were operated on according to our surgical strategy. Our surgical strategy was as follows; early surgery, appropriate releasing of CSF, appropriate surgical approach, using neuronavigating system, securing the bridging veins, using temporary clipping and/or tentative clipping, meticulous manipulation of aneurysm, and using micro-Doppler flow probe. Twenty of 23 patients who had complete medical records were studied retrospectively. We observed the postoperative radiographic findings and checked Glasgow Outcome Scale score sixth months after the operation. RESULTS: Nineteen DACA aneurysms were clipped through a unilateral interhemispheric approach and one DACA aneurysm was clipped through a pterional approach. Postoperative radiographic findings revealed complete clipping of aneurysmal neck without stenosis or occlusion of parent arteries. In two patients, a residual neck of aneurysm was visualized. Seventeen patients showed good recovery, one patient resulted in moderate disability, while 2 patients died. CONCLUSION: With our surgical strategy it was possible to achieve acceptable surgical morbidity and mortality rates in patients with DACA aneurysms. Appropriate use of tentative clipping, temporary clipping and neuro-navigating systems can give great help for safe approach and clipping of DACA aneurysm.

Multiple Aneurysms of the Distal Anterior Cerebral Artery: Case Report

Saccular aneurysms of the distal anterior cerebral artery are relatively rare, ranging from 1.5 to 9.2% of all intracranial aneurysms. A 61-year old woman presented with headache and nuchal rigidity. Cerebral angiographic image demonstrated multiple aneurysms of the distal anterior cerebral artery. We report a case of multiple aneurysms of the distal anterior cerebral artery without other vascular anomalies.

Pure Acute Subdural Hematoma without Subarachnoid Haemorrhage Caused by Rupture of Distal Anterior Cerebral Artery Aneurysm / 대한뇌혈관외과학회지

A 64-year-old female presented with unconscious state after sudden onset headache, nausea and vomiting. Computed tomography showed acute subdural hematoma (SDH) over the left convexity without subarachnoid hemorrhage. 3D-CT angiogram showed a saccular aneurysm at the junction of A2-A3 of the left anterior cerebral artery. Surgery for decompressive craniotomy and aneurysmal neck clipping was performed. In operative field, the left distal anterior cerebral artery was abnormally elongated toward the frontal pole and located not in the pericallosal cistern but on the cortical surface and the rupturing point was located in the adhesive portion of aneurysmal sac and arachnoid membrane near the falx. Pure acute SDH without subarachnoid hemorrhage (SAH) caused by ruptured aneurysm is extremely rare. Rupture of an aneurysm adhered to either the dura or falx and located in the subdural space may cause pure SDH. In our case, abnormally elongated location of artery may be related to this adhesion and rupture of aneurysm to subdural space. Therefore, ruptured intracranial aneurysm should be considered as a cause of non-traumatic SDH. Immediate removal of the SDH and aneurysmal clipping is recommended in such patients, even those in poor neurological condition.

Surgical Management of Multiple Aneurysms Including Distal Anterior Cerebral Artery Aneurysms / 대한뇌혈관학회지

OBJECTIVE: The goal of this study is to evaluate the surgical outcome of multiple aneurysms including distal anterior cerebral artery (DACA) aneurysms. MATERIAL AND METHOD: From May 1989 to March 2000, 12 patients with multiple aneurysms including DACA aneurysms, presented with subarachnoid hemorrhage, had been surgically treated. Their medial record and radiological studies were studied retrospectively. Of 12 patients, in 5 patients, all of the aneurysms were clipped through a single craniotomy extended from midline to pterion in one stage, in 5 patients, multiple aneurysms were treated through separate craniotomies in one stage and 2 patients were treated in staged operation. RESULTS: Two patients showed Glasgow Outcome Scale (GOS) 5-4, 2 patients showed GOS 3-2 and 1 patient showed GOS 1 in 5 patients treated through a single craniotomy in one stage, 2 patients showed GOS 5-4 and 3 patients showed GOS 3-2. All patients treated in staged operation showed favorable outcome. CONCLUSION: In surgical management of multiple aneurysms including DACA aneurysms surgery through separate bony windows in two stages seemed to show more favorable outcome.

Interhemispheric Approach for Intracranial Aneurysms / 대한뇌혈관학회지

The author describes the basic and standard operative method of interhemispheric(IH) approach for intracranial aneurysms especially aneurysm in anterior cerebral artery territory.Though most neurosurgeons prefer to pterional approach for anterior communicating artery aneurysm, some neurosurgeons select IH approach routinely for this aneurysm because of least brain retraction and excellent anatomical orientation with this approach. But IH approach should be chosen for distal anterior cerebral artery aneurysms and certain cases of anterior communicating artery aneurysms such as high positioned aneurysm or aneurysm with significant hematoma at frontal lobe. interhemispheric approach.

Surgical Treatment of Distal Anterior Cerebral Artery Aneurysms

The incidence of the distal anterior cerebral artery(DACA) aneurysm comprises about 2-6% of all intracerebral aneurysms. Because of the low incidence, unique anatomies of the distal anterior cerebral arteries and some technical difficulties in surgery, these aneurysms present such challenge to neurosurgeons. Presently, early surgery using interhemispheric approach is preferred. The auhtors experienced six patients with DACA aneurysms in 130 consecutive intracerebral aneurysms surgically treated between May. 1994 and Dec. 1997. The patients received operations within five days from the ictus, except one patient because of symptomatic vasospasm. The surgical approaches were all unilateral interhemispheric approaches. During the operations, infusion of large amount of mannitol and CSF volume removal were applied, although there were few difficulties in the interhemispheric dissections, the outcomes of the patients were excellent in three, good in three. The authors suggest that early operative interventions using unilateral interhemispheric approach without generous craniotomy can improve the outcomes of the patients with ruptured DACA aneurysm.

Ligation of Anterior Superrior Sagittal Sinus in Approaching Distal Anterior Cerebral Artery Aneurysm

Interhemispheric approach has been accepted as a standard method approaching distal anterioir cerebral artery(DACA) aneurysm. In the approach, most authors use the surgical method retracting the superior sagittal sinus(SSS) after dural reflection. However, it results in limited surgical space and makes the surgical procedure difficult technically. To overcome the limitation, we tried to ligate and cut SSS in 13 patients out of 23 patients of DACA aneurysm from Mar. 1983 to Feb. 1993. Out of total 583 intracranial aneurysms operated on in that period, the proportion of DACA aneurysm was 3.95%. Mean age was 52.7 years ranging from 32 to 66 years. The sex ration was 7:16, showing female predominancy. As presenting symptoms, twenty two patients had subrachnoid hemorrhage and one patient had a third nerve palsy due to an unruptured posterior communicating artery aneurysm. On admission, 4 patients(17.4%) were in grade I, 10(43.5%) in grade II, 6(26.1%) in grade III, 3(13%) in grade IV according to the Hunt and Hess grading system. In 18 patients(78.3%), aneurysms were located at bifurcation of pericallosal and callosomarginal artery and in 5(21.7%) at bifurcation of frontopolar and pericallosal artery. Associated vascular anomalies were A1 hypoplasia(2 cases), multiple aneurysms(5 cases), fenestration of anterior cerebral(1 case) and arteriovenous malformation(1 case). Thirteen cases were operated on with ligation of the SSS and 10 without ligation. Overall surgical outcomes scored by Glasgow outcome scale were : 11 patients(47.8%) in Grade I, 6(26.1%) in Grade II, 2(8.7%) in Grade III, 4(17.4%) in Grade V. The outcomes in ligation group were : 8 patients(61.5%) in Grade I, 4(30.8%) in Grade II, 1(7.7%) in Grade III, and no death. The outcomes in non-ligation group were : 4 patients(40%) in Grade I, 1(10%) in Grade II, 1(10%) in Grade III, and 4(40%) in Grade V. These results showed that the patients operated on with ligation of SSS had more favorable outcomes than the patients without ligation. It seems that the SSS in the interhemispheric approach might provide several advantages and better operative outcome over the conventional method.

Four Cases of Surgically Managed Distal Anterior Cerebral Artery Aneurysm

A series of 4 patients with aneurysm of distal anterior cerebral artery(DACA), operated with microtechniques, is reviewed. Because the incidence of aneurysms in this location was only 2 to 4% of that of total aneurysm, little expericences on surgical management of this aneurysm have been reported. An aneurysm in this location is difficult to approach surgically because of their multiplicity, characteristically broad and sclerotic base, with small subarachnoid space in the interhemispheric fissure. We surgically treated DACA aneurysms of 4 cases through the interhemispheric approach via the unilateral frontal paramedian craniotomy on the nondominant side.

Microsurgical Treatment of Distal Anterior Cerebral Artery Aneurysm

Between Jan. 1983 and Dec. 1990, 17 Patients with distal anterior cerebral artery(DACA) aneurysms were admitted to our institute and underwent microsurgical neck clipping of their aneurysms. This group comprised 3.7% of the 437 aneurysms managed surgically during this period. There were 11 females and 6 males. The mean age was 48.5 years. Most of DACA aneurysms were located at the genu portion of the anterior cerebral artery. Three cases were at the proximal protion of A2 close to the anterior communicating artery. Two cases were at the dista pericallosal artery and distal callosomarginal artery. Eight patients had additional vascular anomalies documented by angiography such as multiple aneurysms, azygos DACA and duplication of DACA. Direct neck clipping was possible in all cases through the interhemispheric approach or the frontotemporal approach according to the location. For the interhemispheric apporach preoperative evaluation of the exact location and direction of the aneurysms on the angiogram was important for operative planning. The surgical outcome was good or excellent without any neurological deficits in 17 of the cases. Operative management, clinical features and incidence of vascular anomalies associated with DACA aneurysms are discussed.

Surgical Management of the Distal Anterior Cerebral Artery Aneurysms

The authors described different type of aneurysms in the distal anterior cerebral artery(DACA), which is difficult to approach surgically. there are anomalies of distal anterior cerebral artery in about one fourth and narrow space, which made more careful surgical dissection. We experienced 7 cases of DACA aneurysm, 6 cases of which were treated surgically through the interhemispheric approach via the unilateral frontal paramedian craniotomy on the non-dominant side. Surgical results were anatomical complexities, modern microsurgical technique aided by microscope make the approach more exactly and safely.