J Cerebrovasc Endovasc Neurosurg.  2023 Dec;25(4):462-467. 10.7461/jcen.2023.E2023.01.002.

Intra-aneurysmatic thrombectomy in a distal anterior cerebral artery aneurysm

• Gómez-Amador JL
• Tovar-Romero LA
• Castillo-Matus A
• Marian-Magaña R
• Aragón-Arreola JF
• Sangrador-Deitos MV
• Hernández-Hernández A
• López-Valencia G
• Guinto-Nishimura GY
• Ríos-Zermeño J

• KMID: 2549453
• DOI: http://doi.org/10.7461/jcen.2023.E2023.01.002

Abstract

Thrombectomy procedures following intra-aneurysmatic lesions are extremely rare, and few cases have been reported. This article describes a microsurgical intra-aneurysmatic thrombectomy (MIaT) for a distal anterior cerebral artery (DACA) aneurysm. We present the case of a 48-year-old female that was admitted to the emergency room, showing neurologic deterioration with focal deficits. A computed tomography angiography (CTA) scan revealed an aneurysm located in the distal segment of the left anterior cerebral artery. During the surgical procedure, after clipping, a wellformed clot was visualized through the aneurysm’s wall obstructing the left DACA flow. We proceeded to open the aneurysm’s dome to remove the thrombus and clip the aneurysm neck, re-establishing the flow of the left DACA. Intra-aneurysmatic thrombosis can occur as a complication during clipping, obstructing the distal flow of vital arteries and causing fatal results in the patient’s postoperative status. MIaT is a good technique for restoring the flow of the affected vessel and allows a secure aneurysm clipping after thrombus removal.

Keyword

Intra-aneurysmatic, DACA, Thrombectomy, Vascular neurosurgery, Clipping, Microsurgery

Figure

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  Fig. 1. (A) Axial CTA showing a saccular aneurysm in the distal anterior cerebral artery. (B) 3D-reconstruction of the coronal CTA with evidence of a saccular aneurysm with a superior dome projection between callosomarginal and pericallosal arteries. CTA, computed tomography angiography

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  Fig. 2. (A) Intraoperative images showing the DACA aneurysm clipping with a 7 mm straight clip. (B) Patency of the left pericallosal artery was verified with intravenous fluorescein and no flow was observed. DACA, distal anterior cerebral artery

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  Fig. 3. Artist ilustration showing the steps of microsurgical intra-aneurysmatic thrombectomy. (A) First, the aneurysm dome was opened using microscissors. (B) Microdissector was used to dissect the intra-aneurysmatic clot and remove it. (C) Irrigation using saline solution was employed in order to achieve the artery patency. (D) Final clipping with a 3 mm straight miniclip for the neck rupture and a 7 mm straight clip for complete aneurysm occlusion.

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  Fig. 4. Intraoperative illustrations. (A) Aneurysm’s dome was already cut with microscissors. (B) Microdissector was introduced in the aneurysm’s dome to dissect the intra-aneurysmatic clot. (C) Irrigation with saline solution was used inside the aneurysm to remove the clot and achieve the arterial patency.

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  Fig. 5. (A and B) Sagittal and axial CTA showing the final aneurysm clipping with adequate flow in left DACA. CTA, computed tomography angiography; DACA, distal anterior cerebral artery

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