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|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 5 | Page : 784-785
Multiple mirror aneurysms: Does the embryological perspective merit a special mention?
Tanmoy Kumar Maiti, Subhas Konar, Anil Nanda
Department of Neurosurgery, LSU Health-Shreveport, LA 71130-3932, USA
|Date of Web Publication||6-Oct-2015|
Department of Neurosurgery, LSU Health-Shreveport, LA 71130-3932
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Maiti TK, Konar S, Nanda A. Multiple mirror aneurysms: Does the embryological perspective merit a special mention?. Neurol India 2015;63:784-5
Mirror aneurysms are a special subtype of multiple aneurysms, which are located bilaterally on corresponding arteries. The frequency of mirror aneurysms varies widely from 5% to 40% of all patients with multiple aneurysms. They are more common in middle cerebral artery (MCA), cavernous internal cerebral artery (ICA), and posterior communicating artery. However, multiple mirror aneurysms in the same patient are exceedingly rare and previously only reported thrice in the literature.,, Embryologically, they may reflect the vulnerability of different arterial segments in a particular stage of development or in a specific disease.
A 73-year-old lady, a hypertensive and smoker, developed a right MCA infarct. During the preliminary imaging, multiple unruptured aneurysms were suspected and a formal four-vessel digital subtraction angiography revealed two pairs of mirror aneurysms involving the cavernous segment of ICA and MCA bifurcation [Figure 1]. There were also an aneurysm each in the proximal part of MCA (sphenoidal segment) (M1) and opercular segment of MCA (M3) on the right side, and the proximal segment of anterior cerebral artery (A1) on the left. Both the cavernous ICA aneurysms were arising from the posterior vertical segment; however, the right one was directed medially whereas the left one was directed inferiorly. The aneurysms in right ICA and MCA were larger than their left counterparts. Multistage treatment was planned. In the first stage, clipping of right MCA bifurcation aneurysm was carried out as it was the largest. However, she developed a right MCA infarct postoperatively from which she gradually recovered. She refused any further intervention thereafter.
|Figure 1: (a) Angiogram of right internal cerebral artery showing aneurysms in cavernous internal cerebral artery (10.7 mm × 10 mm with neck of 5.8 mm) and middle cerebral artery bifurcation (11.7 mm × 8.7 mm with a neck of 5.2 mm). (b) Angiogram of left internal cerebral artery showing aneurysms in cavernous internal cerebral artery (2 mm × 1.6 mm with a neck of 2.1 mm) and middle cerebral artery bifurcation (4.3 mm × 3.8 mm with a neck of 3.1 mm)|
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Baccin et al. discussed the development of intracranial basal arteries from three embryological segments. Multiple aneurysms commonly present in identical or adjacent segments and suggest the presence of a specific trigger during the cephalic segmentation. On the contrary, presence in a nonadjacent segment possibly reflects the occurrence of the defect prior to cephalic segmentation, and a systemic or familial cause may be associated. Interestingly, one patient, having the latter type of multiple mirror aneurysms, had multiple first-degree relatives with ruptured intracranial aneurysms. Among the four cases of multiple mirror aneurysms [Table 1], including the present case, the aneurysms were located in identical segments in two patients and in nonadjacent segments in the other two. In our patient, although there were a total of seven aneurysms, all of them were in the embryological prosencephalic region. In all described cases of mirror aneurysms, the size, shape, and direction of aneurysms were not exactly same when compared to their mirror counterparts. The present patient never experienced subarachnoid hemorrhage (SAH) which makes her distinct from the previously described cases.
The mere presence of mirror aneurysms does not increase the chance of SAH. However, they are more common in young, female patients with a family history of aneurysmal SAH and have a larger size at rupture than nonmirror multiple aneurysms., Nevertheless, the presence of mirror aneurysms creates confusion in formulating a management strategy and the presence of multiple mirror aneurysms only adds to that. The choice has to be made not only between clipping and coiling but also between single stage and multiple stages. The management should be individualised for every patient to ensure the patient's safety.
Multiple mirror aneurysms represent the rare occurrence of a diverse pathology. A similar discussion can hypothesize the possible theories of development, inheritance pattern and association, and the need for screening of first-degree relatives.
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There are no conflicts of interest.
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