Distal Anterior Cerebral Artery Aneurysms: Endovascular or Surgical Treatment?

Abstract

Cerebral aneurysms are occasionally associated with anomalies of the cerebral arteries. Most reports on anomalies of the anterior cerebral artery have been concerned with hypoplasia, fenestration and the infra-optic course of the A1, variant A1 perforators or Heubner's artery, multi-channeled anterior communicating artery, and azygos anterior cerebral artery. Distal anterior cerebral artery (ACA) aneurysms are known to have a poor clinical course and prognosis compared to other supratentorial aneurysms. The presence of the unpaired, distal, postcommunicating (A2) segment of the ACA is very rare in adults. We describe a patient with a ruptured aneurysm arising from the proximal end of the azygos ACA, first surgically treated with clipping and then with endovascular coiling. A 37-year-old woman at 34 weeks' gestation was transferred to our emergency room with sudden onset of severe headache and vomiting. Computed tomography (CT) revealed subarachnoid hemorrhage in the basal cisterna and the sylvian and interhemispheric fissures. Cerebral angiography showed an azygos ACA, a saccular aneurysm at the junction of the azygos ACA and the right A1 segment. A right fronto-temporal craniotomy was performed in the day of admission, and the neck of the aneurysm was clipped. One year later, an angiographic control examination revealed a regrowth of the aneurysm. The patient underwent endovascular treatment with coiling. Aneurysms of the azygos ACA are rare and their pathogenesis and course are still a matter of discussion. Developmental abnormalities or dynamic vessel wall stresses can explain the high incidence of aneurysms in these cases. The association of a rare anatomical variant with an aneurysm in the same location may suggest an embryogenesis alteration in the Willis circulation.

Prevalence of axis II comorbidities in bipolar disorder: relationship to mood state

“…In addition, the state of depression and its associated depressive cognitions may color in a negative fashion patients’ self‐report of personality disorder characteristics and traits. In either case, some presumptive personality disorders may disappear with effective treatment of the Axis I disorder and the achievement of euthymia However, the severity of manic symptoms assessed on the YMRS was also associated with more personality disorder characteristics, suggesting that symptom overlap rather than just depressive cognitions are relevant to the relationships. Since the paired data within individual subjects mirrored the group data for depressed and euthymic subjects, it would appear that personality disorder diagnoses obtained in depression (and perhaps in mania as well) are to some extent state‐ rather than trait‐related characteristics, and achieving clinical improvement and the euthymic state does not represent a true improvement in personality disorders.…”

Giant saccular distal azygos artery aneurysm: Report of a case and review of literature

“…[ 1 4 7 ] Table 1 summarizes all cases of azygos ACA aneurysms reported in the literature since the year 2000. [ 1 3 5 6 7 8 9 10 11 12 13 14 15 16 17 18 ]…”

“…[1,4,7] Table 1 summarizes all cases of azygos ACA aneurysms reported in the literature since the year 2000. [1,3,[5][6][7][8][9][10][11][12][13][14][15][16][17][18] Baptista after a review of 381 brain specimens described three types of distal ACA. [12] Type 1 is single, unpaired distal ACA, also called azygos ACA, which gives off branches to medial surface of both the cerebral hemispheres.…”

“…Coiling of azygous ACA aneurysm, clipping of MCA trifurcation aneurysm Good Saponiero et al [14] 37/female + 2 Proximal, saccular -Clipping followed by coiling 1 year later Good Jagetia et al [3] 58/female + 3 Wide neck, saccular, bilobed No Clipping Death. pulmonary embolism Bapuraj et al [5] 45/female + -Saccular Aneurysm of basilar artery Clipping -40/female + -Saccular Clipping -Huh et al [2] 66/female + -Saccular -Clipping Good 74/female + -Saccular -Clipping Death 78/female + HH grade 3 Saccular -Clipping Good Chen et al [15] 59/male + Distal Clipping Good Auguste et al [1] 46 [16] 59/female + 2 Proximal, saccular Fenestration of right hypoplastic A1 Clipping Good Mori et al [17] 73/female + 5 Proximal, saccular with pseudoaneurysm Clipping Death Topsakal et al [4] 65/female + 3 Saccular, trilobed, giant Aneurysm of M1 segment Clipping Death (nonsurgical) Kanemoto et al [7] 77/female − -Distal, giant, thrombosed -Clipping Good Dietrich et al [18] 52 In the present case, patient presented with subarachnoid hemorrhage due to rupture of distal azygos ACA an aneurysm.…”

Stenting-assisted embolization of a saccular aneurysm of the azygos anterior cerebral artery associated with fenestration at its beginning

“…1 However, once endovascular treatment can be chosen, it is an appealing treatment option for saccular AACA aneurysms, especially ruptured aneurysms that are associated with swollen brains. 2 In this era of evolving endovascular technology and techniques, there are an increasing number of choices to treat saccular AACA aneurysms, including single coiling with double microcatheters, stenting or balloon-assisted coiling, and the waffle-cone technique to assist coiling. 20,22,23 Even with the assistance of the double microcatheter technique, single coiling is not always safe for AACA wide-necked aneurysms, and coil migration can occur.…”