- Department of Neurosurgery, Saga University, Saga, Japan
Department of Neurosurgery, Saga University, Saga, Japan
DOI:10.4103/2152-7806.85608Copyright: © 2011 Matsushima K. 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: Matsushima K, Kawashima M, Suzuyama K, Takase Y, Takao T, Matsushima T. Thrombosed giant aneurysm of the distal anterior cerebral artery treated with aneurysm resection and proximal pericallosal artery–callosomarginal artery end-to-end anastomosis: Case report and review of the literature. Surg Neurol Int 30-Sep-2011;2:135
How to cite this URL: Matsushima K, Kawashima M, Suzuyama K, Takase Y, Takao T, Matsushima T. Thrombosed giant aneurysm of the distal anterior cerebral artery treated with aneurysm resection and proximal pericallosal artery–callosomarginal artery end-to-end anastomosis: Case report and review of the literature. Surg Neurol Int 30-Sep-2011;2:135. Available from: http://sni.wpengine.com/surgicalint_articles/thrombosed-giant-aneurysm-of-the-distal-anterior-cerebral-artery-treated-with-aneurysm-resection-and-proximal-pericallosal-artery-callosomarginal-artery-end-to-end-anastomosis-case-report-and/
Background:Giant distal anterior cerebral artery (DACA) aneurysms are extremely rare, with only 32 cases reported in the literature. Most giant DACA aneurysms have features that make standard neck clipping difficult, and bypass surgery is sometimes required, although this surgery was performed in only three reported cases. This report presents the fourth case treated with bypass surgery.
Case Description:A 69-year-old female presented with an unruptured thrombosed giant DACA aneurysm. She underwent wrapping operation 7 years before, but radiological imaging revealed enlargement of the aneurysm at the left pericallosal artery (PerA)–callosomarginal artery (CMA) junction. Before operation, three different strategies were considered for bypass surgery in case the neck could not be clipped. Aneurysm resection and left proximal PerA–CMA end-to-end anastomosis were successfully performed under intraoperative digital subtraction angiography (DSA) and motor-evoked potential (MEP) monitoring.
Conclusion:Most DACA aneurysms are located at the PerA–CMA junction. In some cases, adequate retrograde flow to the distal PerA from the posterior or middle cerebral artery can be expected, making distal PerA reconstruction unnecessary. Moreover, when the distal PerA is cut, proximal PerA–CMA end-to-end anastomosis can be easily performed because of reduced tension in both vessels. We therefore conclude that this strategy should be utilized for treating such patients. We also presented here the effectiveness of intraoperative modalities, such as intraoperative DSA and MEP monitoring, for performing a safe operation.
Keywords: Bypass surgery, distal anterior cerebral artery, end-to-end anastomosis, intraoperative modalities, pericallosal artery, thrombosed giant aneurysm
Distal anterior cerebral artery (DACA) aneurysms are rare, comprising approximately 5% of all intracranial aneurysms.[
We successfully treated an elderly woman who presented with a partially thrombosed giant DACA aneurysm with aneurysm resection and proximal pericallosal artery (PerA)–callosomarginal artery (CMA) end-to-end anastomosis. We report here surgical treatments available for giant DACA aneurysms and the effectiveness of intraoperative modalities for performing a safe operation.
In August 2003, a 69-year-old female who had hypertension and an abdominal aortic aneurysm complained of dizziness. A computed tomography (CT) scan showed a 15-mm heterogeneous mass in the cerebral left frontal lobe [
Follow-up images of the aneurysm. (a) Axial computed tomography scan before the first operation in 2003 showing a 15-mm heterogeneous mass in the left frontal lobe. (b) Axial computed tomography scan on admission in 2010 showing a 28-mm giant aneurysm with perifocaledema. The aneurysm is growing up with calcification. (c) Preoperative axial T2-weighted magnetic resonance imaging showing clear high signal intensity of marked perifocaledema in the white matter around the aneurysm. (d) The anteroposterior view of preoperative 3-dimensional computed tomography angiography showing three aneurysms, including a distal anterior cerebral artery aneurysm, an anterior communicating artery aneurysm (short arrow) and a right middle cerebral artery aneurysm (long arrow). (e) The left oblique view of preoperative 3-dimensional digital subtraction angiography of the left internal carotid artery showing the aneurysm at the pericallosal artery (PerA, short arrow)–callosomarginal artery (CMA, long arrow) junction
In September 2010, magnetic resonance angiography at a local hospital revealed enlargement of the aneurysm, and the patient was admitted to our hospital. Neurological examinations did not show any abnormal findings. A CT scan [
Because of the obvious enlargement of the aneurysm and perifocaledema, we planned surgical treatment. Standard neck clipping [
Illustrations showing four possible surgical strategies. Reconstruction for the left distal PerA was to be decided during operation. (b) Shows the reconstructive procedure for the left distal PerA, and (c) and (d) show the surgical strategies requiring no reconstruction. (a) Neck clipping. (b) Left A2 trapping plus A3–A3 side-to-side anastomosis with reconstruction of the left distal PerA by right CMA–left distal PerA side-to-end anastomosis. (c) Left A2 trapping plus bonnet bypass using a short graft of the right superficial temporal artery. (d) Aneurysm resection plus proximal PerA–CMA end-to-end anastomosis
Intraoperative DSA and transcranial motor-evoked potential (MEP) monitoring were performed in this operation. Bifrontal craniotomy was performed on the patient under general anesthesia. Initially, the neck of an AcomA aneurysm was clipped using the interhemispheric approach. We proceeded distally along both A2 vessels and found the DACA aneurysm at the left PerA–CMA junction. The aneurysm was yellowish and solid because of severe calcification [
Intraoperative photographs taken during the interhemispheric approach. (a) A yellowish solid aneurysm (box) at the left PerA (short arrow)–CMA (long arrow) junction. (b) Thrombectomy of the aneurysm while trapping the aneurysm after cutting the left distal PerA. The neck of the aneurysm is highly calcified. (c) Left proximal PerA–CMA end-to-end anastomosis
Temporary clips were placed on the left A2 segment and left CMA to trap the aneurysm. The aneurysm was incised and the thrombus within the aneurysm was removed. After removal of the thrombus, three lumens were visualized in the aneurysm [
Intraoperative digital subtraction angiography of the left internal carotid artery (oblique views). (a) Left internal carotid angiogram showing the aneurysm at the left PerA (short arrow)–CMA (long arrow) junction. (b) Left internal carotid angiogram under occlusion of the left A2 segment, showing good retrograde flow to the left distal PerA (arrow) from the left middle cerebral artery through leptomeningeal anastomosis (arrow). (c) Left internal carotid angiogram after aneurysm resection and proximal PerA–CMA end-to-end anastomosis, showing elimination of the distal anterior cerebral artery aneurysm (arrow head) and good recanalization of the left CMA (arrow)
The patient had no neurological deficits after operation, and the postoperative CT scan demonstrated no infarction including the left ACA territory [
Postoperative computed tomography scan and 3-dimensional CT angiography. (a) Computed tomography scan after operation showing no ischemic lesion in the left anterior cerebral artery territory. (b) The oblique view of postoperative 3-dimensional CT angiography showing elimination of the aneurysm and good recanalization of the left callosomarginal artery (arrow)
Giant intracranial aneurysms (>25 mm in diameter) comprise approximately 5% of all intracranial aneurysms,[
Although the natural history of unruptured giant intracranial aneurysms has not been sufficiently clarified, many authors reported high rupture rates and high mortality.[
Most DACA aneurysms arise at the PerA–CMA junction.[
Giant DACA aneurysms are extremely rare. This may be due to their tendency to rupture early. This feature may be related to anatomical features such as the lack of resistant arachnoid membranes at the level of the pericallosal cisterns.[
In our case, standard neck clipping with preservation of the parent artery was impossible because of severe calcification. A3–A3 side-to-side anastomosis seemed difficult in the narrow and deep working space in the interhemispheric fissure, and it might have required longer occlusion time. Furthermore, the bonnet bypass using the right superficial temporal artery was suspected to cause ischemia of the scalp in our case. Eventually, PerA–CMA end-to-end anastomosis with aneurysm resection was selected as the most appropriate treatment.
End-to-end anastomosis with aneurysm resection is usually excluded as a treatment for aneurysms because the vessels cannot be anastomosed as a result of their lengths. However, in some cases of aneurysm at the PerA–CMA junction, adequate retrograde flow in the distal PerA can be expected because PerA is supplied from the posterior cerebral artery through the posterior PerA or from MCA through leptomeningeal anastomosis. In such cases, reconstruction of the distal PerA is not necessary. Moreover, when the distal PerA is cut, proximal PerA–CMA end-to-end anastomosis becomes easier because the anastomosis site becomes more flexible and tension at this site reduces.
For safe treatment of giant aneurysms, it is very important to plan alternative strategies before operation and change the strategy during operation if necessary. Moreover, intraoperative modalities including intraoperative DSA and MEP monitoring are helpful in deciding the strategy. In our case, the distal PerA could be cut without any reconstruction because adequate retrograde flow was observed in DSA. The decreased MEP amplitude suggested occlusion of the parent artery, and the recovery of MEP amplitude suggested preservation of the parent artery. After anastomosis, intraoperative DSA and microvascular Doppler ultrasonography proved good patency of anastomosis.
Giant DACA aneurysms are extremely rare, and surgical treatment is very difficult in most cases. We conclude that proximal PerA–CMA end-to-end anastomosis with aneurysm resection is a useful treatment for thrombosed giant DACA aneurysms at the PerA–CMA junction, especially when the distal PerA can be cut. In this report, we also presented the effectiveness of intraoperative modalities, such as intraoperative DSA and MEP monitoring, for performing a safe operation.
We would like to express our gratitude to Mrs. Akiko Soejima, Mrs. Takako Shiga and Mrs. Sumiko Matsushima for their assistance in preparing and completing this manuscript.
1. Anson JA, Awad IA, Barrow DL.editors. Giant aneurysms. Epidemiology and natural history. Giant Cerebral Aneurysms. Park Ridge IL: AANS; 1995. p.
2. Barrow DL, Alleyne C. Natural history of giant intracranial aneurysms and indications for intervension. Clin Neurosurg. 1995. 42: 214-44
3. Biondi A, Jean B, Vivas E, Le Jean L, Boch AL, Chiras J. Giant and large peripheral cerebral aneurysms: Etiopathologic considerations, endovascular treatment, and long-term follow-up. AJNR Am J Neuroradiol. 2006. 27: 1685-92
4. De Sousa AA, Dantas FL, de Cardoso GT, Costa BS. Distal anterior cerebral artery aneurysms. Surg Neurol. 1999. 52: 128-36
5. Drake CG. Giant intracranial aneurysms: Experience with surgical treatment in 174 patients. Clin Neurosurg. 1979. 26: 12-95
6. Ewald CH, Kuhne D, Hassler WE. Bypass-surgery and coil-embolisation in the treatment of cerebral giant aneurysms. Acta Neurochir (Wien). 2000. 142: 731-8
7. Farias JP, Trindade AM. Giant distal anterior cerebral artery aneurysm not visualized on angiography: Case report. Surg Neurol. 1997. 48: 348-51
8. Gelfenbeyn M, Natarajan SK, Sekhar LN. Large distal anterior cerebral artery aneurysm treated with resection and interposition graft: Case report. Neurosurgery. 2009. 64: E1008-9
9. Hashizume K, Nukui H, Horikoshi T, Kaneko M, Fukamachi A. Giant aneurysm of the azygous anterior cerebral artery associated with acute subdural hematoma.Case report. Neurol Med Chir (Tokyo). 1999. 32: 693-7
10. Hayashi M, Kobayashi H, Kawano H, Handa Y, Kabuto M. Giant aneurysm of an azygous anterior cerebral artery: Report of two cases and review of the literature. Neurosurgery. 1985. 17: 341-4
11. Hernesniemi J, Tapaninaho A, Vapalahti M, Niskanen M, Kari A, Lukkonen M. Saccular aneurysms of the distal anterior cerebral artery and its branches. Neurosurgery. 1992. 31: 994-9
12. Hoh BL, Putman CM, Budzik RF, Carter BS, Ogilvy CS. Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization. J Neurosurg. 2001. 95: 24-35
13. Kanemoto Y, Tanaka Y, Nonaka M, Hironaka Y. Giant aneurysm of the azygos anterior cerebral artery: Case report. Neurol Med Chir (Tokyo). 2000. 40: 472-5
14. Kawashima M, Matsushima T, Sasaki T. Surgical strategy for distal anterior cerebral artery aneurysms: Microsurgical anatomy. J Neurosurg. 2003. 99: 517-25
15. Koyama S. Giant aneurysm of the pericallosal artery causing acute subdural hematoma: Case report. Neurol Med Chir (Tokyo). 2000. 40: 268-71
16. Lawton MT, Spetzler RF. Surgical management of giant intracranial aneursyms: Experience with 171 patients. Clin Neurosurg. 1995. 42: 245-66
17. Maiuri F, Corriero G, D’Amico L, Simonetti L. Giant aneurysm of the pericallosal artery. Neurosurgery. 1990. 26: 703-6
18. Mishima K, Watanabe T, Sasaki T, Saito I, Takakura K. An infected partially thrombosed giant aneurysm of the azygous anterior cerebral artery. No Shinkei Geka. 1990. 18: 475-81
19. Nitta T, Nakajima K, Maeda M, Ishii S. Completely thrombosed giant aneurysm of the pericallosal artery: Case report. J Comput Tomogr. 1987. 11: 140-3
20. O’Neill M, Hope T, Thompson G. Giant intracranial aneurysms: Diagnosis with special reference to computerized tomography. Clin Radiol. 1979. 31: 27-36
21. Park DH, Chung YG, Shin IY, Lee JB, Suh JK, Lee HK. Thrombosed giant aneurysm of the pericallosal artery with inconclusive findings of multiple neuroimaging studies: Case report. Neurol Med Chir (Tokyo). 2008. 48: 26-9
22. Peerless SJ, Wallace MC, Drake CG, Youmans JR.editors. Giant intracranial aneurysms. Neurological Surgery. Philadelphia, PA: WB Saunders; 1990. p. 1742-63
23. Pia HW, Zierski J, Pia HW, Langmaid C, Zierski J.editors. Giant cerebral aneurysms: Problems in treatment. Cerebral aneurysms. Advances in diagnosis and therapy. Berlin: Springer; 1979. p. 336-42
24. Pozzati E, Nuzzo G, Gaist G. Giant aneurysm of the pericallosal artery: Case report. J Neurosurg. 1982. 57: 566-9
25. Preul M, Tampieri D, Leblanc R. Giant aneurysm of the distal anterior cerebral artery: Associated with an anterior communicating artery aneurysm and dural arteriovenous fistula. Surg Neurol. 1992. 38: 347-52
26. Shigemori M, Kawaba T, Ogata T, Yoshimura K, Kuramoto S. Giant aneurysm of the distal anterior cerebral artery simulating brain tumor on CT scan. CT Kenkyu. 1982. 4: 456-9
27. Shiokawa K, Tanikawa T, Satoh K, Kawamata T, Kubo O, Kagawa M. Two cases of giant aneurysms arising from the distal segment of the anterior ccerebral circulation. No Shinkei Geka. 1993. 21: 467-72
28. Sindou M, Guyotat IP, Mertens P, Keravel Y, Athayde AA. Pericallosal aneurysms. Surg Neurol. 1988. 30: 434-40
29. Smith RR, Parent AD. End-to-end anastomosis of the anterior cerebral artery after excision of a giant aneurysm: Case report. J Neurosurg. 1982. 56: 577-80
30. Steven DA, Lownie SP, Ferguson GG. Aneurysms of the distal anterior cerebral artery: Results in 59 consecutively managed patients. Neurosurgery. 2007. 60: 227-34
31. Topskal C, Ozveren MF, Erol FS, Cihangiroglu M, Cetin H. Giant aneurysm of the azygous pericallosal artery: Case report and review of the literature. Surg Neurol. 2003. 60: 524-33
32. Ture U, Hicdonmez T, Elmaci I, Peker S. Giant pericallosal artery aneurysm: Case report and review of the literature. Neurosurg Rev. 2001. 24: 151-5
33. Wiebers DO, Whisnant JP, Huston J, Meissner I, Brown RD, Piepgras DG. International study of unruptured intracranial aneurysms investigators. Lancet. 2003. 362: 103-10
34. Yamagami T, Handa H, Hashimoto N, Nagata H, Watanabe H. Giant aneurysm of the azygous anterior cerebral artery. Arch Jpn Chir. 1986. 55: 777-82
35. Yasargil MG.editors. Microneurosurgery. New York: Georg Thieme Verlag; 1984. 1:
36. Yokoh A, Ausman JI, Dujovny M, Diaz FG, Berman SK, Sanders J. Anterior cerebral artery reconstruction. Neurosurgery. 1986. 19: 26-35