- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Pediatric Neurosurgery, Children's Hospital, Birmingham, AL 35233, USA
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
Aaron A. Cohen-Gadol
Pediatric Neurosurgery, Children's Hospital, Birmingham, AL 35233, USA
DOI:10.4103/2152-7806.80121Copyright: © 2011 Shoja MM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Shoja MM, Tubbs RS, Cohen-Gadol AA. Acute formation of a pseudoaneurysm adjacent to a previously clipped anterior communicating artery aneurysm. Surg Neurol Int 28-Apr-2011;2:56
How to cite this URL: Shoja MM, Tubbs RS, Cohen-Gadol AA. Acute formation of a pseudoaneurysm adjacent to a previously clipped anterior communicating artery aneurysm. Surg Neurol Int 28-Apr-2011;2:56. Available from: http://sni.wpengine.com/surgicalint_articles/acute-formation-of-a-pseudoaneurysm-adjacent-to-a-previously-clipped-anterior-communicating-artery-aneurysm/
Background:Cerebral pseudoaneurysms, especially of the anterior communicating artery (ACoA), are rare.
Case Description:Herein, the authors report a 66-year-old patient who underwent successful clip ligation of a small ruptured ACoA aneurysm. Eighteen days after surgery, he suffered from another episode of subarachnoid hemorrhage due to the rupture of a newly formed pseudoaneurysm adjacent to the previously clipped aneurysm. This pseudoaneurysm was treated through clip ligation as well.
Conclusion:A pseudoaneurysm may rarely form adjacent to a previously clipped cerebral aneurysm and should be included in the differential diagnosis of recurrent subarachnoid hemorrhage. Potential mechanisms of formation and management strategies for this challenging problem will be discussed.
Keywords: False aneurysm, clip ligation, intracranial aneurysm, subarachnoid hemorrhage
Intracranial pseudoaneurysms encompass less than 1% of all intracranial arterial dilations.[
Pseudoaneurysm formation has been reported as a cause of early rebleeding following cerebral aneurysm coiling.[
A 66-year-old man with an acute onset of headache and a brief period of loss of consciousness was diagnosed with acute subarachnoid hemorrhage and his cerebral angiogram revealed a small ACoA aneurysm [
The patient's neurological status remained stable postoperatively. A CT angiogram done 3 days later, as part of the work-up to assess for worsening confusion, revealed mild anterior circulation vasospasm without any evidence of residual or recurrent aneurysm [
A repeat four-vessel cerebral angiogram [anteroposterior (a) and oblique (b) views] without 3D reconstructions 9 days after the initial surgery revealed mild right A1 and A2 vasospasm without any evidence of residual or recurrent aneurysm. A potential aneurysmal abnormality was retrospectively detected (arrow)
Endovascular attempts at aneurysm occlusion were again unsuccessful. A repeat right frontotemporal craniotomy was performed on the same day, and we clipped the newly diagnosed aneurysm by placing a 6-mm fenestrated clip across the ACoA and included the proximal A2 in the clip's fenestration. The aneurysm was found to barely contain a wall; its neck was located about 2 mm posterior to the neck of the original aneurysm and originated from the superior aspect of the ACoA. This aneurysm was not apparent during the first surgery despite a thorough inspection of the region. The clip from the first surgery was not manipulated and was noted to completely occlude the neck of the original aneurysm. Clip application during the second surgery was challenging due to the presence of the clip from the first surgery.
An intraoperative angiogram revealed reasonable occlusion of the aneurysm with its minimal faint filling and contrast stasis. A portion of the ACoA was noted to be significantly stenosed by the clip. Since other attempts at clip repositioning to keep the ACoA patent led to further filling of the aneurysm, we determined that sacrificing a portion of the ACoA, which did not harbor any hypothalamic perforator, was acceptable.
Two postoperative follow-up CT angiograms, performed 3 days apart, revealed no further growth of the pseudoaneurysm. Two weeks after the second surgery, a repeat cerebral angiogram revealed no significant residual aneurysm [
Previous reports of ACoA pseudoaneurysms have been related to blunt head trauma[
Cosgrove et al.[
The present report indicates that although rare, acute formation of a pseudoaneurysm adjacent to a previously clipped intracranial aneurysm should be considered in the differential diagnosis of early subarachnoid rebleeding following intracranial aneurysm clipping. The surgical management of secondary, fragile pseudoaneurysm may be challenging and sacrifice of the ACoA may be necessary.
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