Primary End-to-end Anastomosis of Anterior Cerebral Artery Dissecting Aneurysm: Technical Case Report and Review of The Literature

Abstract

OBJECTIVE AND IMPORTANCE: Subarachnoid hemorrhage caused by an isolated dissection of the anterior cerebral artery (ACA) is an extremely rare problem. The optimal treatment for patients with this clinical scenario varies and is controversial in the literature. We report a patient with a hemorrhage from a distal ACA dissecting aneurysm at presentation 2 years after an arteriovenous malformation resection, who was treated effectively with excision of the diseased segment and direct revascularization of the ACA. We report this as the first case of delayed hemorrhagic arterial dissection after arteriovenous malformation resection treated with early revascularization. We review this rare topic and present our perspective on the method of treatment of ACA dissection. CLINICAL PRESENTATION: A 32-year-old woman was transferred to the University of Texas Southwestern Medical Center and admitted with subarachnoid and intraventricular hemorrhage. Angiography revealed the source of the hemorrhage to be a dissecting aneurysm of the pericallosal artery. INTERVENTION:The patient underwent surgery on the third day after hemorrhage for excision of the dissecting aneurysm and in situ primary anastomosis of the pericallosal artery. Exposure and anastomosis of the pericallosal artery was facilitated by partial resection of the genu of the corpus callosum. CONCLUSION: On the basis of our experience and review of the literature regarding this topic, an optimal treatment for a dissecting aneurysm with hemorrhage involving the pericallosal portion of the ACA at presentation is excision of the diseased segment followed by revascularization. This treatment should prevent rehemorrhage from the aneurysm and avoid iatrogenic ischemic complications to the ACA territory that would be likely with trapping of the aneurysm without revascularization.

Dissecting Aneurysms of Bilateral Anterior Cerebral Artery Complicated by Subarachnoid Hemorrhage after Cerebral Infarction: A Case Report

“…[ 3 , 6 ] Most of the cases demonstrating DA in the periphery of the A2 segment were treated conservatively. [ 2 , 6 , 7 ] There were only six articles in the literature in which DA occurred in the periphery of the A2 segment and was treated surgically, three cases underwent trapping with revascularization,[ 8 ] and two underwent trapping without revascularization. [ 9 ] Another one case underwent embolization of DA with endovascular surgery.…”

“…Because there were DAs bilaterally, we could not perform vascular anastomosis. [ 7 ] Naturally, trapping the A2 segment without revascularization is associated with risks of ischemia to the ACA territory distal to the trapped vessel. However we suggest that trapping without vascular anastomosis is needed to prevent re-bleeding in certain cases.…”