J Korean Neurosurg Soc.  2024 Nov;67(6):675-681. 10.3340/jkns.2024.0069.

Successive Development and Rupture of Blister-Like Anterior Communicating Artery Aneurysms at Mirror Locations

• Kim M
• Park J

• KMID: 2560409
• DOI: http://doi.org/10.3340/jkns.2024.0069

Abstract

This is the first report of the successive development and rupture of blister-like anterior communicating artery (ACoA) aneurysms at mirror locations with a short interval. A 49-year-old man presented with an angiogram-negative subarachnoid hemorrhage with significant basal frontal interhemispheric blood. Surgical exploration revealed a blister-like aneurysm on the left side of the superior wall of the ACoA, which was treated using a microsuturing technique. On the 18th day after the initial subarachnoid hemorrhage, the second operation due to another angiogram-negative hemorrhage revealed a de novo blister-like aneurysm with a small blood clot on the posterosuperior wall of the ACoA close to the right A1/A2 junction. The rupture point and ACoA on the right side were occluded using an aneurysm clip. Follow-up digital subtraction angiogram at 4 years and computed tomography angiogram at 14 years after the surgery showed no recurrence or associated abnormality.

Keyword

Craniotomy; Aneurysm, anterior communicating artery; Subarachnoid hemorrhage; Blister-like aneurysm

Figure

• 

  Fig. 1. Initial radiological images on admission. A : Computed tomography scan showing a diffuse subarachnoid hemorrhage in the basal cisterns. The more pronounced collection of blood (arrow) in the inferior part of the frontal interhemispheric cistern suggests a hemorrhage from a ruptured ACoA aneurysm. B : CTA showing a small aneurysm (arrow) at the bifurcation of the right middle cerebral artery. C : CTA showing no lesion in the ACoA (arrow). ACoA : anterior communicating artery, CTA : computed tomography angiogram.

• 

  Fig. 2. Intraoperative photographs of the first pterional craniotomy. A : Small unruptured aneurysm (arrow) at the bifurcation of the right middle cerebral artery. B : Small blood clot (double arrows) attached to the superior wall of the ACoA (arrow). C : Arterial hole (arrow) in the superior wall of the ACoA on the left side, which was exposed after careful removal of the blood clot. D : Three stitches (arrow) using 9-0 monofilament closing the arterial hole in the ACoA. ACoA : anterior communicating artery.

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  Fig. 3. Radiological images after the second hemorrhage. A : Computed tomography scan demonstrating an intracerebral hemorrhage (arrow) in the right frontal base starting from the ACoA region and associated intraventricular hemorrhage in the whole ventricular system. B : Digital subtraction angiogram showing no aneurysmal bulge or stenosis in the ACoA (arrow). ACoA : anterior communicating artery.

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  Fig. 4. Intraoperative photographs of the second operation. A : De novo blister-like aneurysm with a small blood clot (arrow) on the posterosuperior wall of the ACoA close to the right A1/A2 junction. B : Angled fenestrated clip that was placed through the A1 segment with the clip blades occluding the rupture point and ACoA. ACoA : anterior communicating artery.

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  Fig. 5. Follow-up digital subtraction angiogram 4 years after the initial subarachnoid hemorrhage. A : Right carotid angiogram showing an angled fenestrated clip occluding the rupture point and ACoA on the right side close to the right A1/A2 junction. B : Left carotid angiogram showing an intact ACoA stump (arrow) on the left side, suggesting an intact ACoA perforator. ACoA : anterior communicating artery.

Reference

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