LARGE DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSM TREATED WITH RESECTION AND INTERPOSITION GRAFT

Abstract OBJECTIVE Distal anterior cerebral artery (DACA) aneurysms are rare, representing only 2% to 6.7% of all intracranial aneurysms. Most of them are small. Large and giant aneurysms are even rarer in this location. Only 26 giant pericallosal (PC) aneurysms have been reported thus far. Various surgical techniques have been used to treat these aneurysms, including direct aneurysm neck clipping, aneurysm trapping, proximal occlusion of the anterior cerebral artery, or a combination of clipping with coiling or a bypass procedure. The report presents an unusual case of a complex DACA aneurysm managed by resection and interposition arterial graft. CLINICAL PRESENTATION A 69-year-old woman presented with acute onset of a severe headache. A digital subtraction angiogram showed a partially thrombosed, complex broad-necked A2–A3 junction aneurysm involving the origin of PC and callosomarginal vessels with a probability of a dissection of the DACA. The left PC artery was significantly narrowed. Because of the complex neck and involvement of the origin of PC and callosomarginal arteries, endovascular treatment was not possible, and microsurgical treatment was planned. TECHNIQUE A large, partially thrombosed, and fusiform anterior cerebral artery A2–A3 aneurysm, with evidence of previous bleeding, was found and treated with resection and a short interposition graft using a segment of the superficial temporal artery. CONCLUSION Surgical treatment of a large DACA aneurysm may be difficult due to a complex neck and the involvement of the branch vessels. Resection and interposition grafting and A3–A3 or A4–A4 anastomoses are treatment options for such patients.

Download Full-text

Superficial Temporal Artery Extended Interposition Graft to Anterior Cerebral Artery Bypass for the Treatment of a Large Fusiform Distal Anterior Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab239 ◽

2021 ◽

Author(s):

Bhanu Jayanand Sudhir ◽

Sanjay Honavalli Murali ◽

Mohamed Amjad Jamaluddin ◽

Easwer Hariharan Venkat

Keyword(s):

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Artery Bypass ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Uneventful Recovery ◽

Interposition Graft ◽

Marginal Artery ◽

Fisher Grade ◽

Distal Anterior Cerebral Artery

Abstract Fusiform aneurysms of the distal anterior cerebral artery (DACA) are infrequent. Clip reconstruction and sequential progressive clipping have been described in the management of giant thrombosed DACA aneurysms.1,2 Customized revascularization with bypass, side-to-side anastomosis, and trapping of the aneurysmal segment have also been performed for treating DACA aneurysms.3-12 We present a 2-dimensional operative video of superficial temporal artery (STA) to distal anterior cerebral artery bypass, followed by trapping of the aneurysm-bearing segment. A 57-yr-old lady presented with a large ruptured subcallosal fusiform DACA aneurysm (WFNS grade 1, Fisher grade 1). Angiography revealed a 1.3 × 0.9 cm fusiform aneurysm in the DACA. Informed consent was secured from the patient and her family for the surgery and permission was obtained for the publication of the patient's image/surgical video. The frontal and parietal branches of the STA were dissected. The parietal branch was explanted and used as a free interposition graft between the frontal branch (end-to-end anastomosis) and calloso-marginal artery (end-to-side anastomosis). After confirming blood flow through the bypass using Doppler, the aneurysm was trapped and excised. The patient had an uneventful recovery. Her postoperative computed tomography (CT) head revealed no evidence of neurological insult. The patency of the bypass conduit and the complete removal of the aneurysm were confirmed using a digital subtraction angiogram. Histopathological examination revealed an eccentric atheromatous plaque with a lipid core. There was no evidence of intraplaque hemorrhage. This extended STA graft utilizing the frontal and parietal branches of the STA, and its implantation into the distal ACA, offers a novel bypass strategy for tackling fusiform aneurysms of the DACA. Anastomosis to the calloso-marginal artery ensured perfusion of the ACA territory through the pericallosal artery during temporary occlusion.

Download Full-text