Combined interhemispheric and pterional approach for ACOM and left MCA aneurysms

Retractorless combined pterional and interhemispheric approach to achieve proximal control in pericallosal artery aneurysm: how I do it

BACKGROUND

Pericallosal artery aneurysms differ from other cerebral aneurysms for the difficulty in establishing proximal vascular control during surgical clipping. A frontomedial craniotomy with combined pterional and interhemispheric approach allows obtaining a better proximal control.

MATERIALS AND METHODS

We present our surgical technique to achieve a proximal vessel control in pericallosal artery aneurysm clipping using a combined pterional and interhemispheric approach through frontomedial craniotomy. This surgical technique is illustrated by an intraoperative video.

CONCLUSION

Proximal control for pericallosal artery aneurysm clipping can be challenging. In selected cases, a single craniotomy allows performing two approaches and obtaining a safer proximal control for surgical clipping.

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

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.

Pterional or Subfrontal Access for Proximal Vascular Control in Anterior Interhemispheric Approach for Ruptured Pericallosal Artery Aneurysms at Risk of Premature Rupture

OBJECTIVE

Cases of a ruptured pericallosal artery aneurysm with a high risk of intraoperative premature rupture and technical difficulties for proximal vascular control require a technique for the early and safe establishment of proximal vascular control.

METHODS

A combined pterional or subfrontal approach exposes the bilateral A1 segments or the origin of the ipsilateral A2 segment of the anterior cerebral artery (ACA) for proximal vascular control. Proximal control far from the ruptured aneurysm facilitates tentative clipping of the rupture point of the aneurysm without a catastrophic premature rupture. The proximal control is then switched to the pericallosal artery just proximal to the aneurysm and its intermittent clipping facilitates complete aneurysm dissection and neck clipping.

RESULTS

Three such cases are reported: a ruptured pericallosal artery aneurysm with a contained leak of the contrast from the proximal side of the aneurysm, a low-lying ruptured pericallosal artery aneurysm with irregularities on its proximal wall, and a multilobulated ruptured pericallosal artery aneurysm with the parasagittal bridging veins hindering surgical access to the proximal parent artery. In each case, the proposed combined pterional-interhemispheric or subfrontal-interhemispheric approach was successfully performed to establish proximal vascular control far from the ruptured aneurysm and facilitated aneurysm clipping via the interhemispheric approach.

CONCLUSION

When using an anterior interhemispheric approach for a ruptured pericallosal artery aneurysm with a high risk of premature rupture, a pterional or subfrontal approach can be combined to establish early proximal vascular control at the bilateral A1 segments or the origin of the A2 segment.