- Department of Neurosurgery, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
Department of Neurosurgery, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
DOI:10.4103/2152-7806.82251Copyright: © 2011 Mitsuhara T 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: Mitsuhara T, Sakamoto S, Kiura Y, Kurisu K. Endovascular coil embolization for ruptured kissing aneurysms associated with A1 fenestration. Surg Neurol Int 21-Jun-2011;2:85
How to cite this URL: Mitsuhara T, Sakamoto S, Kiura Y, Kurisu K. Endovascular coil embolization for ruptured kissing aneurysms associated with A1 fenestration. Surg Neurol Int 21-Jun-2011;2:85. Available from: http://sni.wpengine.com/surgicalint_articles/endovascular-coil-embolization-for-ruptured-kissing-aneurysms-associated-with-a1-fenestration/
Background:Fenestration of intracranial arteries is a rare anomaly, and is frequently associated with cerebral aneurysms. In this paper, we report rare kissing aneurysms associated with A1 fenestration.
Case Description:A 71-year-old woman presented with subarachnoid hemorrhage. Diagnostic digital subtraction angiography revealed two saccular aneurysms at the proximal junction of a fenestration and posterior aspect of the fenestration that appeared to be ‘kissing’ each other. Emergent endovascular coil embolization was performed.
Conclusion:Kissing aneurysms associated with fenestration of the horizontal segment in the anterior cerebral artery are rare, and have not been reported. During treatment of such specific types of aneurysms by endovascular treatment, three-dimensional rotational digital subtraction angiography was very useful for deciding the appropriate working angles.
Keywords: Coil embolization, fenestration, kissing aneurysms, ruptured aneurysm, three-dimensional rotational digital subtraction angiogram
Ever since the advent of cerebral angiography, fenestrations of the intracranial arteries associated with saccular aneurysms are a well-recognized anomaly, and an increasing number of such cases have been reported over the years.[
A 71-year-old woman presented with severe headache of acute onset. Head computed tomography (CT) showed Grade I subarachnoid hemorrhage (SAH, Fisher Grade 3) of the Hunt and Hess grading system. CT angiography revealed an aneurysm with a bleb in the right A1 segment. Three-dimensional (3D) CT image reconstruction revealed a segmental duplication of the distal one-third of the right A1 segment, associated with an irregular aneurysm and blebs[
Emergent endovascular coil embolization was performed for each of the aneurysms. A 7F guiding catheter (Guider Softip XF; Boston Scientific, Fremont, CA, USA) was introduced into the right proximal internal carotid artery under general anesthesia and systemic heparinization. Before the coil embolization, diagnostic digital subtraction angiography revealed two saccular aneurysms at the proximal junction of the fenestration and posterior aspect of the fenestration that appeared to be “kissing” each other. 3D image reconstruction revealed small bleb formation in each of the aneurysms. Because we could not determine which of the aneurysms was ruptured, we decided to treat each by coil embolization. During the endovascular procedure, we used 3D angiographic reconstruction to determine the appropriate working angle for separating the aneurysmal sac from the fenestration[
We used a support catheter (Cerulean G40; Medikit Co., Tokyo, Japan) to lead the microcatheter into the distal A1. A microcatheter (Excelsior SL-10; Boston Scientific) was placed within the posterior distal aneurysm. The aneurysmal sac and neck were successfully packed with several detachable coils. Then, we treated the proximal aneurysm at the proximal bifurcation of the fenestration using the same technique. Another microcatheter (Excelsior SL-10 Pre-shaped S; Boston Scientific) was selected for obtaining safe aneurysmal catheterization and adequate stability during the coil placement. Because the aneurysm had a wide neck above the bifurcation, we packed only the aneurysmal sac with a detachable bioactive coil (DELTAPAQ CERECYTE, Micrus Endovascular San Jose, CA, USA) to preserve both channels of the fenestrated A1. The postoperative course was uneventful, and the patient was discharged without any neurologic deficits.
Fenestrations are observed in 0.3-0.9% of cerebral angiograms and are frequently located in the vertebral artery and the basilar artery.[
The term “kissing aneurysms” refers to two anatomically adjacent aneurysms with different origins and partially adherent walls. In the intracranial circulation, these aneurysms are quite rare and there have been no previous reports in the literature of kissing aneurysms associated with A1 fenestration.[
In previous reports, neck clipping was the standard treatment for aneurysms associated with fenestrations[
There are, however, some difficulties in the endovascular treatment for kissing aneurysms.[
In the present case, we performed successful coil embolization for kissing aneurysms associated with A1 fenestration and preserved both channels of the fenestrated A1 branches. The biplane 3D rotational digital subtraction technique enabled us to determine the most useful working angle for treating these complicated aneurysms.
We have reported kissing aneurysms associated with fenestration of the horizontal segment of the anterior cerebral artery. To treat such specific types of aneurysms by endovascular techniques, we successfully used rotational angiography and 3D image reconstruction. For the management of kissing aneurysms, endovascular coil surgery is considered as an attractive treatment strategy and 3D rotational digital subtraction angiography is an important tool for achieving safe coil embolization.
First of all, I compliment you on your technical achievement.
Second, I personally believe that this is a dangerous approach to use, as the anatomy can be seen more directly and controlled from an intracranial perspective than by the indirect interventional approach. You did not know which aneurysm bled. The anatomy is complex and needs to be seen directly with temporary clipping to understand the anatomy so that proper clip application can be made. I suspect that if you had 100 of these cases that the complication rate would be significant by the endovascular approach. That is my opinion. I hope that in the future, others will report their cases, and that a true value in the interventional approach can be determined with more cases in the literature at that time. At this time, I would advise others to treat such aneurysms directly by surgery.
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