scholarly journals Right Orbitozygomatic Craniotomy for Clip Wrapping of an A2 Fusiform Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (4) ◽  
pp. E155-E156
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Video Recording ◽  
Fusiform Aneurysm ◽  
Anterior Circulation ◽  
Institutional Review ◽  
Aneurysmal Dilation ◽  
Interhemispheric Fissure ◽  
Flow Through ◽  
Distal Anterior Cerebral Artery

Abstract Distal anterior cerebral artery aneurysms often rupture at a small size and are associated with overall higher operative morbidity relative to other anterior circulation aneurysms. This patient had an incidentally identified anterior cerebral artery proximal A2 segment fusiform aneurysm that did not respond to endovascular treatment and required open surgical management. The fusiform dilation was mobilized and isolated circumferentially within the interhemispheric fissure, and a Gore-Tex clip-wrapping was planned. A permanent clip was applied along the aneurysmal dilation parallel to the vessel directly prior to completing the wrapping to attempt to establish native flow dynamics through the aneurysmal segment. The clip-wrapping was then completed, and intraoperative indocyanine green fluoroscopy demonstrated good distal flow through the aneurysmal segment. The patient gave informed consent for surgery and video recording. The institutional review board approval was deemed unnecessary. Used with permission from the Barrow Neurological Institute, Phoenix, Arizona.

Left A2 Fusiform Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (2) ◽  
pp. E142-E142 ◽  
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Video Recording ◽  
Parent Artery ◽  
Fusiform Aneurysm ◽  
Bypass Procedure ◽  
Institutional Review ◽  
Interhemispheric Fissure ◽  
Aneurysm Thrombosis ◽  
Wide Neck

Abstract Anterior cerebral artery aneurysms within the A2 segment that are fusiform or giant A2 aneurysms with a wide neck often are not candidates for endovascular treatment and require surgical intervention. These lesions necessitate a bypass procedure to preserve distal flow along the anterior cerebral artery. This patient demonstrated a left-sided unruptured A2 fusiform aneurysm that necessitated a bypass procedure for management. The patient was positioned with the head rotated laterally to permit orientation of the interhemispheric fissure within the horizontal plane and achieve gravity retraction of the dependent hemisphere. The bilateral pericallosal branches were exposed and liberated from arachnoid adhesions to permit mobilization necessary for the side-to-side anastomosis. While the anastomosis was performed, the continuous suture loops were left loose to permit complete visualization of the inner and outer walls prior to the final tightening and tying of the anastomotic suture. Following the completion of the anastomosis, the temporary clips were removed. A permanent clip was placed on the distal A2 to prevent outflow from the parent artery and thereby allow for aneurysm thrombosis. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Surgical Management of a Ruptured Dissecting Anterior Cerebral Artery (A2) Aneurysm Utilizing Contralateral Frontopolar for Reconstruction: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (3) ◽  
pp. E76-E77
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Video Recording ◽  
Dissecting Aneurysm ◽  
Institutional Review ◽  
Interhemispheric Fissure ◽  
Diseased Vessel ◽  
Temporary Clip ◽  
Rupture Site ◽  
Fibrin Thrombus

Abstract Dissecting aneurysms can pose an immense surgical challenge, and intervention often involves high risk for rerupture because of the volatile nature of the fibrin thrombus overlying the rupture site. This patient presented following rupture of a dissecting aneurysm along the A2 segment of the anterior cerebral artery (ACA). The patient underwent a right orbitozygomatic craniotomy, and the aneurysm was approached within the interhemispheric fissure. Manipulation of the aneurysm dome resulted in intraoperative rerupture of the aneurysm, which was controlled by the application of a temporary clip on the parent A2 proximally and distally. Aneurysmectomy of the thin diseased vessel wall was performed. The defect was filled by transecting the frontopolar branch of the ACA and sewing the frontopolar branch onto the aneurysmectomy defect. This provided a suitable patch for the ACA defect. Postprocedural indocyanine green angiography demonstrated patency of the A2 and the anastomosed frontopolar branch. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Treatment of a Fusiform Anterior Cerebral Artery Aneurysm With an A3-A3 Bypass: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E385-E385
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Neurological Status ◽  
Institutional Review ◽  
Bypass Patency ◽  
Surgical Field ◽  
Distal Anterior Cerebral Artery ◽  
Cerebral Artery Aneurysm

Abstract Distal anterior cerebral artery (ACA) aneurysms remain a relatively rare and challenging entity for both open microsurgical and endovascular treatments. These lesions provide a significant surgical challenge because of the narrow interhemispheric surgical field, limited proximal control, common fixation of the aneurysm to the adjacent cingulate gyrus, and possible involvement of an unpaired azygos A2. These challenges result in a known association between distal ACA aneurysms and higher operative morbidity. This video demonstrates indirect obliteration of a prior ruptured fusiform right A2 aneurysm utilizing an A3-to-A3 side-to-side anastomotic bypass with aneurysm trapping. An anterior interhemispheric approach was used for exposure of bilateral ACAs, arteriotomies, microanastomosis, and trapping of the aneurysmal right A2 segment. Postoperatively, the patient's neurological status returned to baseline, and imaging demonstrated evidence of bypass patency with no residual filling of the fusiform aneurysmal segment. This video verifies the feasibility and efficacy of the A3-to-A3 anastomotic bypass for treatment of distal ACA aneurysms. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

In Situ Side-to-Side Pericallosal-Pericallosal Artery and Callosomarginal-Callosomarginal Artery Bypasses for Complex Distal Anterior Cerebral Artery Aneurysms: A Technical Note

2020 ◽  
Vol 19 (5) ◽  
pp. E487-E495
Author(s):  
Francesco Acerbi ◽  
Ignazio G Vetrano ◽  
Jacopo Falco ◽  
Andrea Gioppo ◽  
Andrea Ciuffi ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Clinical Status ◽  
Endovascular Embolization ◽  
Technical Note ◽  
Neurological Deficits ◽  
Complex Aneurysms ◽  
Innovative Solution ◽  
Interhemispheric Fissure ◽  
Distal Anterior Cerebral Artery

Abstract BACKGROUND Despite surgical and endovascular technical improvements over the last decades, the treatment of complex aneurysms of the distal anterior cerebral artery (ACA) is very challenging for both vascular neurosurgeons and interventional neuroradiologists. Furthermore, the interpersonal anatomic variability requires, most of the time, a tailored planning. OBJECTIVE To describe a novel technique of bypasses in the territory of ACA to protect the brain territory distal to the aneurysm. METHODS A 53-yr-old male with a large complex fusiform aneurysm of the left distal A2 segment of the ACA, involving the origin of the callosomarginal and pericallosal arteries, was judged not suitable for a single procedure (endovascular or neurosurgical). Two side-to-side bypasses were performed in a single surgery to connect the pericallosal and callosomarginal arteries of both sides, distally to the aneurysm. Subsequently, an endovascular embolization of the aneurysm was achieved with coils. RESULTS The patency of the microanastomoses, performed in the anterior interhemispheric fissure, was positively evaluated intraoperatively with indocyanine green and fluorescein videoangiography. The aneurysm sac, together with proximal A2 segment, was completely occluded with platinum coils. At the last follow-up, computed tomography angiography confirmed the patency of both bypasses, without any sign of aneurysm recanalization. The patients never complained of any focal neurological deficits or worsening of clinical status. CONCLUSION We present an elegant and innovative solution to completely protect the distal ACA territory in cases of complex aneurysm involving the origin of both callosomarginal and pericallosal arteries.

Saccular aneurysms of the distal anterior cerebral artery

1974 ◽  
Vol 40 (2) ◽  
pp. 218-223 ◽  
Author(s):  
M. Gazi Yaşargil ◽  
L. Philip Carter
Keyword(s):  
Cerebral Artery ◽  
Subarachnoid Space ◽  
Operative Mortality ◽  
Anterior Cerebral Artery ◽  
Operative Morbidity ◽  
Content Type ◽  
Interhemispheric Fissure ◽  
Distal Anterior Cerebral Artery ◽  
Fine Print ◽  
Saccular Aneurysms

✓ A series of 13 patients with saccular aneurysms of the distal anterior cerebral artery, operated on by the same surgeon with microtechniques, is reviewed. The incidence of aneurysms in this location was 3.4%, the median age of the patients 44 years, and the median time from most recent hemorrhage to surgery 13 days. There were five cases of multiple aneurysms. No operative mortality occurred; the operative morbidity was 15%. Because of their multiplicity, characteristic broad base, and the small subarachnoid space in the interhemispheric fissure, these aneurysms are judged technically difficult.

scholarly journals Contemporary Management of Distal Anterior Cerebral Artery Aneurysms: A Dual-Trained Neurosurgeon's Perspective

2021 ◽  
Author(s):  
Sunil V. Furtado ◽  
Dravya Jayakumar ◽  
Parichay J. Perikal ◽  
Dilip Mohan
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Statistical Significance ◽  
Endovascular Coiling ◽  
World Federation ◽  
Anterior Circulation ◽  
Chi Square ◽  
Good Outcome ◽  
Fisher Grade ◽  
Distal Anterior Cerebral Artery

Abstract Objectives Distal anterior cerebral artery (DACA) aneurysms are a subset of aneurysms located in the anterior circulation but away from the circle of Willis. We analyze the clinical presentation and outcomes of two treatment groups—surgical and endovascular—for DACA aneurysms managed by a dual-trained neurosurgeon. Material and Methods A retrospective evaluation of radiological and operative/interventional data of 34 patients with 35 DACA aneurysms over a 12-year period was analyzed. Twenty-seven patients underwent surgery, whereas seven underwent endovascular coiling of the aneurysms. Modified Fisher grade and World Federation of Neurosurgical Societies scale (WFNS) were used to note the subarachnoid hemorrhage (SAH) severity. Statistical Analysis Categorical data were presented as frequency and percentage, while noncategorical data were represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using Chi-square test, and p < 0.05 was considered statistically significant. Results Of 34 patients, 33 presented with a bleed and 23.5% patients were noted to have another aneurysm in addition to the DACA aneurysm. Patients who underwent clipping for another aneurysm along with the DACA aneurysm in a single surgical exercise had a poor outcome compared with those who underwent surgery for the lone DACA aneurysm (7 vs. 20, p = 0.015). Most patients in both surgical (70.37%) and endovascular (85.71%) groups had good outcome (mRS ≤ 2). Conclusions A good outcome can be achieved with either surgery or endovascular coiling in the management of DACA aneurysms. In patients with multiple aneurysms, SAH with aneurysmal rupture of DACA should be managed first; the other unruptured aneurysm may be operated after an interval to avoid morbidity.

scholarly journals Hematoma expansion unrelated to rebleeding in ruptured anterior cerebral artery aneurysms treated by early endovascular embolization

2021 ◽  
Vol 12 ◽  
pp. 571
Author(s):  
Kazuaki Okamura ◽  
Yoichi Morofuji ◽  
Nobutaka Horie ◽  
Tsuyoshi Izumo ◽  
Kei Sato ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Medical Records ◽  
Anterior Cerebral Artery ◽  
Cerebral Aneurysms ◽  
Endovascular Embolization ◽  
Hematoma Expansion ◽  
Interhemispheric Fissure ◽  
Systemic Anticoagulation ◽  
Distal Anterior Cerebral Artery ◽  
Aneurysm Coiling

Background: Whether hematoma expansion after aneurysmal rupture is always a sign of rerupture remains unclear. Hence, the present study aimed to assess the incidence and risk factors of hematoma expansion unrelated to aneurysmal rerupture after endovascular embolization for ruptured cerebral aneurysms. Methods: We included patients who underwent endovascular embolization for ruptured cerebral aneurysms within 48 h after onset at our institution between January 2009 and February 2014. The medical records of 70 consecutive patients were reviewed and analyzed retrospectively. Results: Hematoma expansion unrelated to aneurysmal rerupture occurred in 7 (10%) of 70 patients. Interestingly, four of seven patients had distal anterior cerebral artery (ACA) aneurysms. The interval from onset to aneurysm coiling was shorter in patients with hematoma expansion than in those without (P = 0.040). Conclusion: Early embolization of ruptured ACA aneurysms might increase the risk of hematoma expansion unrelated to aneurysmal rerupture because the procedures were conducted under systemic anticoagulation. It would be better to refer the patient for direct clipping if the patient has a distal ACA aneurysm with parenchymal hematoma at interhemispheric fissure. Delayed coil embolization, which means around 12–18 h delayed, might be another option for ruptured distal ACA aneurysms to prevent hematoma expansion.

A3-A3 Bypass for Giant Anterior Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (1) ◽  
pp. E47-E48
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Distal Segment ◽  
Institutional Review ◽  
Diseased Vessel ◽  
Distal Perfusion ◽  
The Right ◽  
Cerebral Artery Aneurysm

Abstract Large fusiform anterior cerebral artery aneurysms often require revascularization to allow for the treatment of the aneurysm and preservation of distal perfusion. The A3-A3 side-to-side anastomosis maintains ipsilateral distal perfusion. The inflow to the fusiform segment can then be clip occluded to treat the diseased vessel segment. This procedure is illustrated by the case in this video. The patient had a large right anterior cerebral artery fusiform aneurysm. An anterior interhemispheric craniotomy with the right side down was utilized for the approach. Postprocedural angiography demonstrated occlusion of the aneurysmal segment and patent distal perfusion within the ipsilateral distal segment. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Interhemispheric approach with callosal resection for distal anterior cerebral artery aneurysms

1992 ◽  
Vol 77 (3) ◽  
pp. 481-483 ◽  
Author(s):  
Vincent C. Traynelis ◽  
Ralph O. Dunker
Keyword(s):  
Corpus Callosum ◽  
Cerebral Artery ◽  
Early Identification ◽  
Anterior Cerebral Artery ◽  
Feeding Artery ◽  
Content Type ◽  
Interhemispheric Approach ◽  
Interhemispheric Fissure ◽  
Distal Anterior Cerebral Artery ◽  
Fine Print

✓ Distal anterior cerebral artery aneurysms are commonly found near the genu of the corpus callosum. While these aneurysms may be surgically obliterated through a variety of approaches, exposure via the interhemispheric fissure is used by many surgeons. Early identification of the afferent artery may be difficult with this approach, however, particularly if the aneurysm lies just beneath the genu of the corpus callosum. The authors have modified the interhemispheric approach to distal anterior cerebral artery aneurysms by electively exposing the feeding artery through a small anterior callosotomy. While this maneuver is not necessary for all distal anterior cerebral artery aneurysms, it can greatly enhance exposure in the region just below the genu of the corpus callosum. Experience with this technique in five patients is reported. In all cases, the limited anterior callosotomy enhanced surgical exposure. No morbidity could be attributed to the callosotomy in any patient. It is concluded that, when the interhemispheric approach is used, anterior callosotomy improves exposure of the region just below the genu of the corpus callosum and may be a useful maneuver when treating distal anterior cerebral artery aneurysms.

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