J Cerebrovasc Endovasc Neurosurg.  2022 Dec;24(4):393-397. 10.7461/jcen.2022.E2021.12.001.

Wire perforation of the missed tiny aneurysm originating from the fenestrated A1 segment during the endovascular approach

• Shin SH
• Cho WH
• Cha SH
• Ko JK

• KMID: 2537325
• DOI: http://doi.org/10.7461/jcen.2022.E2021.12.001

Abstract

Vascular anomaly and aneurysmal formation of an anterior communicating artery (ACOM) complex has often been reported. Because of such a complicated relationship between the vascular structure and aneurysms, ACOM aneurysm is one of the most difficult aneurysms to treat among other common anterior circulation aneurysms. We herein report a case of wire perforation of a missed tiny aneurysm arising from the fenestrated A1 segment during the endovascular approach to ACOM aneurysm. Although the fenestration of A1 segment is a rare vascular anomaly, it is likely to accompany saccular type aneurysms in the vicinity of the vascular anomaly. Endovascular treatment for ACOM aneurysm requires more detailed evaluations of the accompanying vascular anomaly and hemodynamics around ACOM to avoid complications.

Keyword

Anterior communicating artery; Cerebral aneurysm; Endovascular; Fenestration

Figure

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  Fig. 1. Subtracted (A) and 3D (B) images of left ICA angiography showing a 7 mm ACOM aneurysm with ACOM fenestration (arrows). ICA, internal carotid artery; ACOM, anterior communicating artery

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  Fig. 2. Leak of contrast agent surrounding mid A1 indicates intraprocedural bleeding, suspecting A1 dissection by microwire.

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  Fig. 3. Unsubtracted image (A) acquired immediately after stent-assisted coiling using the waffle-cone technique (B) shows no more leak of contrast agent with complete aneurysm occlusion.

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  Fig. 4. (A) Repeated cerebral angiography immediately after rebleeding reveals contrast leakage (arrows) from the proximal fenestrated A1 segment. (B) Unsubtracted image shows immediately embolized leaking point using coils (arrow).

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  Fig. 5. Another angle of initial angiography shows a missed tiny aneurysm (arrow) arising from the proximal end of the left fenestrated A1 segment.

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