Multiple aneurysms of the anterior communicating artery: radiological and surgical difficulties

Kissing Aneurysms of the Anterior Communicating Artery Treated With Surgical Clipping: A Case Report and Literature Review

Intracranial "kissing" aneurysms are rare vascular conditions described as two anatomically adjacent aneurysms originating from either the same or different arteries, with their walls pressed together. Two-dimensional angiography was formerly considered the gold standard for diagnosis, with the three-dimensional rotational type now offering more insightful details about vascular discrepancies. The treatment of anterior communicating artery (AcoA) "kissing" aneurysms poses significant challenges, with surgical clipping proving difficult due to their deep midline location or the bilateral anterograde arterial supply. However, advancements in endovascular coil embolization, such as dual-volume reconstruction, can assist in diagnosis. This study presents the case of a 50-year-old patient who was diagnosed with "kissing" aneurysms of the AcoA. The patient underwent surgical clipping and showed no pathological follow-up findings. The surgical intervention often provides a more direct and effective approach. This case contributes to the body of knowledge surrounding the management of this complex disease.

Clipping Could Be the Best Treatment Modality for Recurring Anterior Communicating Artery Aneurysms Treated Endovascularly

BACKGROUND

The anterior communicating artery (AcoA) is the most common location for intracranial aneurysms.

OBJECTIVE

To present occlusion outcomes, complication rate, recurrence rate, and predictors of recurrence in a large cohort with AcoA aneurysms treated primarily with endosaccular embolization. We also attempt to present data on the most effective treatment modality for recurrent AcoA aneurysms.

METHODS

This is a retrospective, single-center study, reviewing the outcomes of 463 AcoA aneurysms treated endovascularly between 2003 and 2018.

RESULTS

The study cohort consisted of 463 patients. Adequate immediate occlusion was achieved in 418 (90.3%). Independent functional status at discharge was observed in 269 patients (58.0%), and the mortality rate was 6.8% (31). At 6 months, adequate occlusion was achieved in 418 (90.4%). Of all the patients, recurrence was observed in 101 cases (21.8%), and of those, 98 (22.4%) underwent retreatment. The combined frequency of retreatment for the coiling group was 42.4%, which was significantly higher than the 0 incident of retreatment in the clipping group (P < .0001). Among the retreatment cohort, there was a significantly higher subsequent retreatment rate in the endovascular group (0% in the clipping group vs 42.4% in the endovascular group, P < .0001).

CONCLUSION

Coiling with and without stent/balloon assistance is a relatively safe and effective modality for the treatment of AcoA aneurysms; however, in the setting of recurrence, microsurgical reconstruction leads to improved outcomes regarding durable occlusion, thus avoiding the potential for multiple interventions in the future.

Vertical diplopia and ptosis from removal of the orbital roof in pterional craniotomy

PURPOSE

To describe a newly recognized clinical syndrome consisting of ptosis, diplopia, vertical gaze limitation, and abduction weakness that can occur after orbital roof removal during orbito-zygomatic-pterional craniotomy.

DESIGN

Case series.

PARTICIPANTS

Eight study patients (7 women), 44 to 80 years of age, with neuro-ophthalmic symptoms after pterional craniotomy.

METHODS

Case description of 8 study patients.

MAIN OUTCOME MEASURES

Presence of ptosis, diplopia, and gaze limitation.

RESULTS

Eight patients had neuro-ophthalmic findings after pterional craniotomy for meningioma removal or aneurysm clipping. The cardinal features were ptosis, limited elevation, and hypotropia. Three patients also had limitation of downgaze and 2 patients had limitation of abduction. Imaging showed loss of the fat layers that normally envelop the superior rectus and levator palpebrae superioris. The muscles appeared attached to the defect in the orbital roof. Ptosis and diplopia developed in 2 patients despite Medpor titanium mesh implants. Deficits in all patients showed spontaneous improvement. In 2 patients, a levator advancement was required to repair ptosis. In 3 patients, an inferior rectus recession using an adjustable suture was performed to treat vertical diplopia. Follow-up a mean of 6.5 years later revealed that all patients had a slight residual upgaze deficit, but alignment was orthotropic in primary gaze.

CONCLUSIONS

After pterional craniotomy, ptosis, diplopia, and vertical gaze limitation can result from tethering of the superior rectus-levator palpebrae superioris complex to the surgical defect in the orbital roof. Lateral rectus function sometimes is compromised by muscle attachment to the lateral orbital osteotomy. This syndrome occurs in approximately 1% of patients after removal of the orbital roof and can be treated, if necessary, by prism glasses or surgery.

Endovascular Therapy of Very Small Aneurysms of the Anterior Communicating Artery: Five-fold Increased Incidence of Rupture

BACKGROUND:

Intraprocedural rupture is a dangerous complication of endovascular treatment. Small ruptured anterior communicating artery (ACoA) aneurysms and microaneurysms present a challenge for both surgical and endovascular therapies to achieve obliteration. An understanding of the complication rates of treating ruptured ACoA microaneurysms may help guide therapeutic options.

OBJECTIVE:

To report the largest cohort of ACoA microaneurysms treated with endovascular therapy over the course of the past 10 years.

METHODS:

We performed a retrospective review of 347 ACoA aneurysms treated in 347 patients at Cleveland Clinic and Emory University over a 10-year period. Patient demographics, aneurysmal rupture, size, use of balloon remodeling, patient outcomes, intraprocedural rupture, and rerupture were reviewed.

RESULTS:

Rupture rates were examined by size for all patients and subgroups and dichotomized to evaluate for size ranges associated with increased rupture rates. The highest risk of rupture was noted in aneurysms less than 4 mm. Of 347 aneurysms, 74 (21%) were less than 4 mm. The intraprocedural rupture rate was 5% (18/347) for ACoA aneurysms of any size. There was an intraprocedural rupture rate of 2.9% (8/273) among ACoA aneurysms greater than 4 mm compared with 13.5% (10/74) in less than 4-mm aneurysms. Procedural rupture was a statistically significant predictor of modified Rankin score after adjusting for Hunt and Hess grades (HH).

CONCLUSION:

ACoA aneurysms less than 4 mm have a 5-fold higher incidence of intraprocedural rerupture during coil embolization. Outcome is negatively affected by intraprocedural rerupture after adjusting for HH grade.

Detailed 3D-morphometry of the anterior communicating artery: potential clinical and neurosurgical implications

PURPOSE

Although a site common for pathology and of great importance to the neurosurgeon, the three-dimensional (3D) morphometry of the anterior communicating artery (ACoA) has had incomplete descriptions in the literature.

METHODS

Using a novel 3D digital-image computer data analysis system, 115 patients underwent evaluation of their ACoA based on DICOM files derived from CT angiography. Measurements included the length, internal diameter, volume, deviation index (DI) and tortuosity index (TI).

RESULTS

Of 115 samples, 85 were visualized clearly enough for morphometric analysis. The mean internal diameter was 1.86 mm and this tended to be greater in males (P < 0.05). The mean length of the ACoA was 3.99 mm and the mean volume was 11.61 mm(3). The mean TI for the ACoA was 0.84 and the mean DI was 0.62 mm. A significant relationship between DI and length, DI and volume, and DI and TI were found. The significant correlation of diameter to volume, and length related to volume, DI and TI, as well as TI related to length, volume and DI were noticed. There were no relationship between any parameter and age.

CONCLUSIONS

A detailed knowledge of the 3D-morphometry of the ACoA demonstrates that in almost 50% of individuals the ACoA is straight in their course. Detailed data regarding arterial topography and trajectory as found in our study may be also of use in detecting early changes in this vessel due to pathology and may assist in the treatment of vascular lesions and planning of neurosurgical or interventional radiological procedures in the region including ACoA aneurysms.