J Cerebrovasc Endovasc Neurosurg.  2023 Dec;25(4):447-451. 10.7461/jcen.2023.E2023.03.003.

Internal carotid artery agenesis presenting with ruptured Acom aneurysm: Rare case report

• Chauhan BPS
• Sahni HS
• Gupta J
• Pandya R
• Patidar J
• Jagetia A

• KMID: 2549451
• DOI: http://doi.org/10.7461/jcen.2023.E2023.03.003

Abstract

Developmental anomalies of internal carotid artery (ICA), being rare entities, are mostly asymptomatic by themselves because of good collateral supply. However, when present with other associated intracranial anomalies requiring treatment, there can be catastrophic consequences, if special attention is not paid to this condition. We present a case of 36 years old male, who reported to our emergency department with complaints of headache and loss of consciousness. He was diagnosed as a case of ruptured anterior communicating aneurysm with subarachnoid hemorrhage and agenesis of left ICA with trans-cavernous anastomosis. He underwent clipping of aneurysm and was discharged uneventfully. This report highlights the importance of skillful microsurgical clipping in extremely high-risk conditions, in contemporary era of hybrid neurosurgeons.

Keyword

ICA agenesis; Trans-cavernous anastomosis; Subarachnoid hemorrhage; Coiling; Clipping

Figure

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  Fig. 1. CT angiogram (head) displaying left ICA agenesis, inter-cavernous anastomosis from right to left ICA, left distal ACA supplied by anterior communicating artery (Acom) via right A1 segment. Small outpouching (aneurysm) can be seen arising from Acom segment. CT, computed tomography; ICA, internal carotid artery; ACA, anterior cerebral artery

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  Fig. 2. Selective right ICA DSA shows saccular aneurysm arising from Acom segment. Trans-cavernous anastomosis can be seen arising from right ICA, which is the sole supply for left MCA. Left distal ACA is supplied by patent Acom artery. ICA, internal carotid artery; DSA, digital substraction angiography; Acom, anterior communicating artery; MCA, middle cerebral artery; ACA, anterior cerebral artery

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  Fig. 3. Noncontrast head CT bony window where darker arrow denotes absent carotid canal on left which has been replaced by pneumatization, lighter arrow denotes patent right carotid canal. CT, computed tomography

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  Fig. 4. (A) Intra-operative microscopic view of clipped A1-Acom junction aneurysm (blue arrow – right A1, black arrow – recurrent artery of Heubner, arrow head – right A2, green arrow – left A1, cross – Acom) (2 clips were applied for complete aneurysm occlusion). (B) Intra-operative microscopic view under ICG guidance where complete occlusion of aneurysm is noted with patent major and perforating vessels. Acom, anterior communicating artery; ICG, indocyanine green

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