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

Middle Cerebral Artery Aneurysm and Distal Anterior Cerebral Artery (DACA) Aneurysms Related to Azygos and an Unusual Single Pericallosal Artery Variant: A Case Report

The authors describe the case of multiple rare distal anterior cerebral artery (DACA) aneurysms related to a middle cerebral artery (MCA) aneurysm, an azygos, and an undescribed anterior cerebral artery (ACA) anatomical variation. A 61-year-old woman in a severe clinical state was diagnosed with subarachnoid hemorrhage (SAH) secondary to a ruptured anterior A3 DACA aneurysm. The patient also had unruptured kissing superior A3 DACA aneurysms, an atherosclerotic DACA aneurysm between the anterior and superior DACA aneurysms, and an unruptured MCA left aneurysm. Two pericallosal anatomical variations were seen: an A2 azygos and a rare single post-bifurcation (callosomarginal artery) pericallosal artery. All aneurysms were clipped using a single-staged left craniotomy with interhemispheric, subfrontal, and transsylvian access. This study demonstrates a patient with rare anatomical ACA variants and multiple complex aneurysms treated in a single-stage craniotomy.

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.

Pericallosal artery aneurysm - Case report, literature review and management outcome

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Pericallosal artery aneurysms are rare.

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They have a higher rupture rate than other anterior circulation intracranial aneurysms.

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These vascular lesions often present with pericallosal intracerebral hematoma.

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Surgical approaches to these aneurysms are associated with a high complication rate.

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Successful management is possible in our low-resource neurosurgical facility.

Introduction

Pericallosal artery aneurysms are rare. Very few cases of this vascular anomaly have been published from West Africa. We report the first case of a ruptured pericallosal artery (PCA) aneurysm managed in a Nigerian neurosurgical facility, with the aim to add to the limited documentation on vascular brain lesions in our sub-region. The management outcome of the index patient and a literature review on these unusual aneurysms were also discussed.

Case report

A middle-aged known hypertensive woman who presented with clinical features of a WFNS grade I subarachnoid hemorrhage (SAH). A plain cranial computerized tomography (CT) scan revealed SAH, a supracallosal intracerebral hematoma and intraventricular hemorrhage. Cranial computerized tomography angiography (CTA) showed a small right pericallosal artery aneurysm, which was treated (with clipping via an interhemispheric approach) in a resource-constrained neurosurgical facility. The patient has remained well over a six-year follow-up period.

Discussion

PCA aneurysms have a high tendency to bleed compared with other supratentorial intracranial aneurysms in spite of their small size. Microsurgical approach, although difficult, is an effective treatment option for these rare aneurysms.

Conclusion

Surgical clipping remains a safe and useful treatment option for pericallosal artery aneurysms in a low-resource neurosurgical facility.