Pericallosal berry aneurysm associated with azygous anterior cerebral artery – a case report

Introduction. Azygos anterior cerebral artery is a rare variant of the anterior segment of the circle of Willis caused by an unusual fusion of the normally paired A2 segments of the anterior cerebral artery (ACA). Despite its rare occurrence, it is associated with various vascular and structural cerebral abnormalities, particularly berry aneurysms. Aim. We aimed to present a case of a 41-year-old female patient who presented to our neurology department with complaints of headache. Description of the case. She had a positive paternal history of aneurysmal subarachnoid hemorrhage. Magnetic resonance angiography (MRA) of her brain revealed an azygos ACA (bifurcating into two pericallosal arteries) which was associated with a saccular aneurysm at its bifurcation point. She was referred to the interventional radiology department for preventive endovascular treatment. Conclusion. Azygos ACA carries a high risk of aneurysm development and its occlusion can potentially compromise blood supply to both cerebral hemispheres. It is therefore crucial for clinicians to be aware of its significance and to report its presence in angiographic studies.

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Aneurysmal subarachnoid hemorrhage in a patient with bilateral A1 fenestrations associated with an azygos anterior cerebral artery

Journal of Neurosurgery ◽

10.3171/jns.1996.84.4.0681 ◽

1996 ◽

Vol 84 (4) ◽

pp. 681-684 ◽

Cited By ~ 42

Author(s):

Robert M. Friedlander ◽

Christopher S. Ogilvy

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Vascular Anatomy ◽

Vascular Anomaly ◽

Rare Occurrence ◽

Content Type ◽

Proximal Anterior Cerebral Artery ◽

Current Article

✓ Fenestration of the proximal anterior cerebral artery (A1 segment) is a rare occurrence. This vascular anomaly is often associated with aneurysms and other abnormalities. The current article describes the case of a 33-year-old man who presented with a subarachnoid hemorrhage secondary to a ruptured aneurysm originating from the proximal end of an A1 fenestration. This patient also had a contralateral A1 fenestration as well as an azygos anterior cerebral artery. This is the first report of such an unusual vascular anatomy. The literature is reviewed and possible embryological mechanisms are discussed.

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Azygous Anterior Cerebral Artery Acute Occlusion Managed With Endovascular Mechanical Thrombectomy: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy183 ◽

2018 ◽

Vol 16 (4) ◽

pp. 514-515 ◽

Cited By ~ 1

Author(s):

Leonardo Rangel-Castilla ◽

Adnan H Siddiqui

Keyword(s):

Cerebral Artery ◽

Cerebral Blood Volume ◽

Mechanical Thrombectomy ◽

Anterior Cerebral Artery ◽

Stent Retriever ◽

Vessel Occlusion ◽

Nihss Score ◽

Acute Occlusion ◽

Intravenous Tissue Plasminogen Activator ◽

Azygous Anterior Cerebral Artery

Abstract Mechanical thrombectomy has become the standard of care for management of most acute large-vessel occlusion (LVO) strokes. Most intracranial occlusions are located in the middle cerebral and internal carotid arteries. We present a unique case of acute occlusion of an azygous anterior cerebral artery (ACA). A 59-yr-old man with known hypertension and alcoholism presented with right hemiparesis, right facial palsy, aphasia, and dysarthria. His initial National Institutes of Health Stroke Scale (NIHSS) score was 20. Computed tomographic angiography and perfusion imaging demonstrated acute bilateral ACA occlusion with viable penumbra and preserved cerebral blood volume. The patient was not a candidate for intravenous tissue plasminogen activator because he presented with a wake-up stroke. After consent was obtained from his family, the patient was taken urgently for endovascular recanalization. Digital subtraction angiography confirmed acute azygous ACA occlusion. Under conscious sedation, the patient underwent mechanical thrombectomy with a stent retriever and a large-bore aspiration catheter. Successful revascularization (thrombolysis in cerebral infarction [TICI] grade 3) of the azygous ACA and both A2 arteries was obtained after 2 attempts and the use of a different stent retriever (first a 3 × 30 mm Trevo [Stryker Neurovascular, Kalamazoo, Michigan] and then a 4 × 40 mm Solitaire Platinum [Medtronic, Dublin, Ireland]). A reperfusion catheter was used during both attempts. No procedure-related complications occurred. The patient was discharged to a rehabilitation facility 3 d after the procedure with an NIHSS score of 2. In this video, we present the operative nuances of an uncommon location of LVO and its endovascular management.

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THE IMPACT OF BALLOON ANGIOPLASTY ON THE EVOLUTION OF VASOSPASM-RELATED INFARCTION AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000311351.32904.8b ◽

2008 ◽

Vol 62 (3) ◽

pp. 610-617 ◽

Cited By ~ 47

Author(s):

Leonie Jestaedt ◽

Mirko Pham ◽

Andreas J. Bartsch ◽

Ekkehard Kunze ◽

Klaus Roosen ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Balloon Angioplasty ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Fisher Exact Test ◽

Computed Tomographic ◽

Fisher Grade ◽

The Impact

Abstract OBJECTIVE Vasospasm of the cerebral vessels remains a major source for morbidity and mortality after aneurysmal subarachnoid hemorrhage. The purpose of this study was to evaluate the frequency of infarction after transluminal balloon angioplasty (TBA) in patients with severe subarachnoid hemorrhage-related vasospasm. METHODS We studied 38 patients (median Hunt and Hess Grade II and median Fisher Grade 4) with angiographically confirmed severe vasospasm (>70% vessel narrowing). A total of 118 vessels with severe vasospasm in the anterior circulation were analyzed. Only the middle cerebral artery, including the terminal internal carotid artery, was treated with TBA (n = 57 vessel segments), whereas the anterior cerebral artery was not treated (n = 61 vessel segments). For both the treated and the untreated vessel territories, infarction on unenhanced computed tomographic scan was assessed as a marker for adverse outcome. RESULTS Infarction after TBA occurred in four middle cerebral artery territories (four out of 57 [7%]), whereas the infarction rate was 23 out of 61 (38%) in the anterior cerebral artery territories not subjected to TBA (P < 0.001, Fisher exact test). Three procedure-related complications occurred during TBA (dissection, n = 1; temporary vessel occlusions, n = 2). One of these remained asymptomatic, whereas this may have contributed to the development of infarction on follow-up computed tomographic scans in two cases. CONCLUSION In a population of patients with a high risk of infarction resulting from vasospasm after subarachnoid hemorrhage, the frequency of infarction in the distribution of vessels undergoing TBA amounts to 7% and is significantly lower than in vessels not undergoing TBA despite some risk inherent to the procedure.

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E-092 azygous anterior cerebral artery aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011917.167 ◽

2015 ◽

Vol 7 (Suppl 1) ◽

pp. A81.2-A82

Author(s):

A Nicholson ◽

D Cooke ◽

M Amans ◽

F Settecase ◽

S Hetts ◽

...

Keyword(s):

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Azygous Anterior Cerebral Artery

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A Ruptured Aneurysm at the Infraoptic Azygous Anterior Cerebral Artery with the Contralateral Internal Carotid Artery Agenesis Treated by Y-stent Assisted Coil Embolization

Journal of Cerebrovascular and Endovascular Neurosurgery ◽

10.7461/jcen.2012.14.3.237 ◽

2012 ◽

Vol 14 (3) ◽

pp. 237 ◽

Cited By ~ 3

Author(s):

Ho-Jun Kang ◽

Yoon-Soo Lee ◽

Sang-Jun Suh ◽

Jeong-Ho Lee ◽

Kee-Young Ryu ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cerebral Artery ◽

Coil Embolization ◽

Internal Carotid ◽

Anterior Cerebral Artery ◽

Ruptured Aneurysm ◽

Contralateral Internal Carotid Artery ◽

Azygous Anterior Cerebral Artery

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Double-Barrel Superficial Temporal Artery-M2 Middle Cerebral Artery Bypass and Creation of a Middle Communicating Artery via M2-M2 End-to-End Reimplantation for Trapping of a Dolichoectatic Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa159 ◽

2020 ◽

Vol 19 (5) ◽

pp. E521-E522

Author(s):

Joshua S Catapano ◽

Fabio A Frisoli ◽

Megan S Cadigan ◽

Dara S Farhadi ◽

Candice L Nguyen ◽

...

Keyword(s):

Family History ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Superficial Temporal Artery ◽

Artery Aneurysm ◽

Temporal Artery ◽

Bypass Patency ◽

History Of ◽

End To End

Abstract Large dolichoectatic aneurysms of middle cerebral artery (MCA) trifurcations are rare and often require trapping and revascularization of the region with a bypass.1-9 This video describes the treatment of an MCA trifurcation aneurysm by clip trapping and double-barrel superficial temporal artery (STA) to M2-MCA bypass followed by M2-M2 end-to-end reimplantation to create a middle communicating artery (MCoA). The patient, a 60-yr-old woman, presented with headache, a history of smoking, and a family history of ruptured aneurysms. Angiography demonstrated a 1.7-cm dolichoectatic aneurysm of the MCA trifurcation. While the natural history of these lesions is unclear, the aneurysm size and family history of aneurysmal subarachnoid hemorrhage were factors in proceeding with treatment. Informed written consent was obtained from the patient and her family. The STA branches were harvested microsurgically, a pterional craniotomy was performed, and the aneurysm was exposed through a transsylvian approach. The two STA branches were anastomosed end-to-side to the middle and inferior trunks of the MCA. Due to the significant mismatch between the donor and recipient vessel calibers, we were concerned that the donors might provide insufficient flow in isolation. Therefore, we decided to transect both M2 trunks from the aneurysm, proximal to the inflow of the bypass, and reimplant them end-to-end. This reimplantation created an MCoA, allowing the two donor arteries to supply the new communication between the inferior and middle trunks, redistributing blood flow through the MCoA according to cerebral demand. Bypass patency and aneurysm obliteration were confirmed on postoperative angiography. At the 6-mo follow-up, the patient's modified Rankin Scale (mRS) score was 0. The MCoA is a novel construct that, like natural communicating arteries, redistributes flow in response to shifting demand, without the need for additional ischemia time during the bypass. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment after subarachnoid hemorrhage

Interventional Neuroradiology ◽

10.1177/1591019917699980 ◽

2017 ◽

Vol 23 (4) ◽

pp. 372-377 ◽

Cited By ~ 7

Author(s):

Nauman S Chaudhry ◽

Jennifer L Orning ◽

Sophia F Shakur ◽

Sepideh Amin-Hanjani ◽

Victor A Aletich ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Artery ◽

Balloon Angioplasty ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Infusion Therapy ◽

Safety And Efficacy ◽

Neurological Improvement ◽

Symptomatic Vasospasm ◽

Radiographic Measurements

Balloon angioplasty is often performed for symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. Angioplasty of the anterior cerebral artery (ACA), however, is perceived to be a challenging endeavor and not routinely performed due to technical and safety concerns. Here, we evaluate the safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment. Patients with vasospasm following subarachnoid hemorrhage who underwent balloon angioplasty at our institution between 2011 and 2016 were retrospectively reviewed. All ACA angioplasty segments were analyzed for pre- and post-angioplasty radiographic measurements. The degree of vasospasm was categorized as mild (<25%), moderate (25–50%), or severe (>50%), and relative change in caliber was measured following treatment. Clinical outcomes following treatment were also assessed. Among 17 patients, 82 total vessel segments and 35 ACA segments were treated with balloon angioplasty. Following angioplasty, 94% of segments had increased caliber. Neurological improvement was noted in 75% of awake patients. There were no intra-procedural complications, but two patients developed ACA territory infarction, despite angioplasty treatment. We demonstrate that balloon angioplasty of the ACA for vasospasm treatment is safe and effective. Thus, ACA angioplasty should be considered to treat vasospasm in symptomatic patients recalcitrant to vasodilation infusion therapy.

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Indocyanine Green Videoangiography for Surgery of a Ruptured Dissecting Aneurysm in the Precommunicating Anterior Cerebral Artery: A Technical Case Report

Operative Neurosurgery ◽

10.1093/ons/opx028 ◽

2017 ◽

Vol 13 (4) ◽

pp. E14-E18 ◽

Cited By ~ 1

Author(s):

Yasunori Nagai ◽

Masanori Goto ◽

Hiroki Toda ◽

Namiko Nishida ◽

Naoya Yoshimoto ◽

...

Keyword(s):

Indocyanine Green ◽

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Connective Tissue Diseases ◽

Vascular Wall ◽

Dissecting Aneurysm ◽

Indocyanine Green Videoangiography ◽

Before And After ◽

History Of ◽

Dissecting Aneurysms

Abstract BACKGROUND AND IMPORTANCE: Indocyanine green videoangiography (ICG-VA) is an important intraoperative adjunct for saccular aneurysm surgery, but its efficacy in surgery for dissecting aneurysms has rarely been reported. The authors describe the usefulness of preclipping ICG-VA in a rare case of a ruptured dissecting aneurysm located at the precommunicating (A1) segment of the anterior cerebral artery. CLINICAL PRESENTATION: A 52-year-old woman, with no history of connective tissue diseases or vascular disorders, presented with sudden headache and convulsion. The CT scan showed that the patient had subarachnoid hemorrhage. Angiography showed a dissecting aneurysm in the left A1 segment of the anterior cerebral artery. Thus, the patient underwent trapping of the dissecting aneurysm. ICG-VA was used as an intraoperative adjunct before and after clipping. The preclipping ICG-VA showed the heterogeneously bright dissecting aneurysm and branching arteries even in the presence of hematoma. CONCLUSION: Preclipping ICG-VA may enhance the advantage of direct surgery for dissecting aneurysm by allowing visualization of the extent of the dissected vascular wall and the related branching arteries. ICG-VA can be an indispensable adjunct to minimize the compromise from the surgical treatment for intracranial dissecting aneurysms.

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