- Department of Neurosurgery, Loghman e Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Neuroradiology, Tooska Medical Imaging Center, Tehran, Iran
Mehrdad Hosseinzadeh Bakhtevari
Department of Neurosurgery, Loghman e Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
DOI:10.4103/2152-7806.166177Copyright: © 2015 Sharifi G. 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: Sharifi G, Bakhtevari MH, Sabouri S, Rezaei O. An aneurysm at the site of the fenestration of the middle cerebral artery in a patient with multiple aneurysms: A case report. Surg Neurol Int 28-Sep-2015;6:
How to cite this URL: Sharifi G, Bakhtevari MH, Sabouri S, Rezaei O. An aneurysm at the site of the fenestration of the middle cerebral artery in a patient with multiple aneurysms: A case report. Surg Neurol Int 28-Sep-2015;6:. Available from: http://surgicalneurologyint.com/surgicalint_articles/an-aneurysm-at-the-site-of-the-fenestration-of-the-middle-cerebral/
Background:Middle cerebral artery (MCA) fenestration is a very rare anatomical variant of the MCA, incidentally found during magnetic resonance or computed tomography angiography. It has an incidence of 0.6%. Unlike fenestration of the posterior cerebral arterial circulation, fenestration of the anterior cerebral arterial circulation has not been well described.
Methods:We present the rare case of a patient who was admitted for a ruptured aneurysm of the MCA arising at the site of the fenestration of the MCA and also an unruptured fusiform aneurysm of the right posterior communicating artery and a distal anterior cerebral artery (ACA) aneurysm.
Results:The patient underwent craniotomy with microsurgical aneurysm clipping and the previously undiagnosed ruptured aneurysm, at the site of the fenestration of the MCA, arose immediately. Postoperatively, the patient awoke without a deficit. After treatment of postoperative bacterial meningitis, he was discharged on the 26th postoperative day in good condition without any neurologic deficit. Six months after the first surgery, he was operated for the distal azygos ACA aneurysm.
Conclusion:Anomalies of the intracranial vasculature are common, and we describe a rare case of left MCA fenestration with an associated ruptured aneurysm at the site of the fenestration. In the literature, cases of fenestration of the MCA are sporadically reported and are only incidental findings.
Keywords: Aneurysm, anterior cerebral artery, fenestration, middle cerebral artery
Anomalies of the intracranial circulation are important for the cerebrovascular surgeons and neurointerventionalists to recognize, especially when the patient is symptomatic. Middle cerebral artery (MCA) variants are encountered less frequently than variants of other intracranial arteries.[
According the literature review, there are three variations of the MCA: Duplicated MCA,[
The fenestrated MCA is usually found incidentally, either during an angiography or an operation performed for pathology, and symptomatic intracranial hemorrhage is very rare.[
A 52-year-old man was transferred to our emergency room with the loss of consciousness and history of a first episode of seizure, 2 h earlier. He had a history of headache during the past several days. He had no previous history of seizure or neurologic signs. In the brief evaluation, his Glasgow Comma Scale was 11, without a focal neurologic deficit. The vital signs were within normal ranges. Emergent computed tomographic (CT) scan revealed SAH in the basal cisterns and both sylvian fissures and anterior interhemispheric region [
The patient underwent surgery, with the left pterional approach. A left frontotemporal craniotomy was performed, and an aneurysm was exposed through the sylvian fissure. The saccular aneurysm, with superior projection in the bifurcation of the left MCA, was clipped with a 7 mm straight clip. After dissection of the aneurysm, fenestration of the MCA was exposed immediately at the aneurysm's site [
Follow-up angiography performed 3 months postoperatively showed complete obstruction of the previous left MCA aneurysms. The second surgery was done 6 months after first surgery. The neurosurgeons opted for a right interhemispheric approach and a saccular aneurysm, with superolateral projection beneath the cingulate gyrus and 15 mm before bifurcation of the pericallosal and callosomarginal arteries was clipped with a 6 mm mini-clip [
Monoparesis of left hand occurred as a complication of the second surgery. Patient muscle force in its left hand was 4/5, with mild spasticity at 4 months follow-up after surgery.
According to Teal et al. study,[
Fenestration is a rare finding, and it is mostly found in the anterior communicating artery (ACoA) or the vertebrobasilar system.[
Okudera et al.[
According to the previous reports, the MCA variants have been regarded to have no clinical significance.[
Rarely, fenestrated MCA can be associated with a major territory infarction from occlusion of the fenestrated segment. Aggressive manipulations during interventional procedures should be avoided to prevent devastating results by arterial rupture.[
Based on Hager Paget's article,[
An anomaly in this stage is the azygos artery or solitary A2 segment that arises when the paired ACAs regress after formation and enlargement of the median ACA. Lin et al.[
This case was very challenging due to the presence of three aneurysms, a ruptured aneurysm immediately at the fenestration site of the MCA, an azygos ACA in the A2 segment and a distal ACA aneurysm.
Although anomalies of the MCA are rare, neurosurgeons and neuroendovascular specialists should be familiar with the anatomic variations and the potential associated findings and sequels that can occur. Furthermore, in patients with multiple aneurysms, they should be aware about the presence of these variations when performing interventions. We suggest more in depth study about multiple aneurysms and variations in the cerebral circulation.
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