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BRIEF REPORT
Year : 2010  |  Volume : 58  |  Issue : 3  |  Page : 446-448

Endovascular treatment of A1 segment aneurysms of the anterior cerebral artery


1 Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
2 Interventional Neuroradiology Department, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Date of Acceptance08-Jun-2010
Date of Web Publication17-Jul-2010

Correspondence Address:
Yunhui Liu
Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang - 110004, Liaoning
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.65538

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 » Abstract 

Aneurysms of the A1 segment of the anterior cerebral artery (ACA) are rare and challenging to treat. We evaluated our experience of endovascular treatment in 11 patients with A1 segment aneurysms of ACA. Seven aneurysms were treated with coiling; three were treated with stent-assisted coiling and one was treated with balloon-assited coiling. Endovascular treatments were technically successful and without complication. Follow-up examinations showed complete cure in all 11 patients.


Keywords: Anterior cerebral artery, endovascular treatment, intracranial aneurysms


How to cite this article:
Yu B, Wu Z, Lv X, Liu Y, Sang M. Endovascular treatment of A1 segment aneurysms of the anterior cerebral artery. Neurol India 2010;58:446-8

How to cite this URL:
Yu B, Wu Z, Lv X, Liu Y, Sang M. Endovascular treatment of A1 segment aneurysms of the anterior cerebral artery. Neurol India [serial online] 2010 [cited 2021 Aug 2];58:446-8. Available from: https://www.neurologyindia.com/text.asp?2010/58/3/446/65538



 » Introduction Top


Aneurysms of the A1 segment of the anterior cerebral artery (ACA) represent less than 1% of all intracranial aneurysms but are important cause of nontraumatic subarachnoid hemorrhage (SAH). [1],[2],[3],[4],[5],[6],[7],[8],[9] Most of these aneurysms are treated by either surgical or endovascular treatment because of the high associated risk of bleeding. [1],[2],[4],[7],[9] There is limited data in the literature concerning the endovascular treatment of A1 segment of ACA. [6],[10] The aim of this study was to report our experience with endovascular treatment and imaging follow-up of 11 patients with A1 aneurysms of ACA.


 » Patients and Methods Top


From January 2007 to December 2009, 1012 patients with 1054 aneurysms were treated in our institution; 11 (1.1%) of them had an A1 segment aneurysms. All the A1 aneurysms were ruptured and indication for treatment was subarachnoid hemorrhage (SAH). The Hunt and Hess grades were 1 in 10 patients and 3 in 1 patient and all were Fischer grade 2 or 3. The size of the aneurysms varied from 1.5 to 6 mm (mean 4.1 mm) and 3 aneurysms had a branch at the neck. Eight aneurysms were superiorly located, a few millimeters after the internal carotid artery (ICA) bifurcation. Endovascular treatment was performed in all the patients. All patients were treated by endosaccular coiling. An Echelon-10 microcatheter (M.T.I-ev3, CA, USA) was used in all patients [Figure 1]. If stent-assisted coiling was required, patients were put on 75 mg clopidogrel and 200 mg aspirin for at least 3 days before the endovascular procedure and were maintained on the same dosage for at least 4 weeks. Aspirin was continued indefinitely. Aneurysm obliteration was evaluated by angiography. Clinical outcome was graded according to a modified Glasgow Outcome Scale (GOS). [11] Patient follow-up angiography was performed at 3-10 months. Further examinations were obtained yearly if needed.


 » Results Top


Eleven patients with A1 segment aneurysms were treated during the study period, and the results are shown in [Table 1]. There were seven men and four women, the mean age was 48.4 years (range 34-75). The maximum dimension of the sac ranged from 1.5 to 6 mm (mean 4.1΁0.9 mm) and aneurysm neck size ranged from 0.8 to 4 mm (mean 1.8΁0.8 mm). Of the 11 aneurysms, seven (63.6%) were narrow-necked and four (36.4%) were wide-necked. The perforating artery was incorporated into the neck in three (27.3%). These aneurysms were treated at choronic stage of SAH, because these patients were referred to our center from local hospitals. Endovascular treatment was successful in all the patients. The stent was also used to protect perforator and parent artery in three patients. The microcatheter was navigated into the aneurysm before stent placement. One Neuroform (Boston Scientific, CA, USA) and two Wingspan (Boston Scientific) stents were used. No technical complication occurred in our patients. Heparin was maintained for 48 h, aspirin (200 mg/day) and clopidogrel (75mg/day) was administered for 6 months if a stent was used. There were no silent, infarctions on post-operative CT scans. All patients showed an excellent clinical outcome (GOS=5). Immediate angiographic control showed a complete occlusion in all cases. Follow-up angiogram was obtained in all the patients and showed complete occlusion.


 » Discussion Top


A1 segment aneurysms of ACA have been diagnosed with increasing frequency probably because of increasing awareness. [6] Our results demonstrate that treatment is indicated for all of these lesions. Natural history of spontaneous rupture has been documented in the literature [1],[3],[7],[9] and was seen in all of our patients. Three-demesion angiography are essential for the diagnosis of these lesions. Treatment can be chosen after assessing location and configuration of the aneurysm, adjacent branches, collateral circulation, and time of presentation. Our study shows that endovascular treatment of A1 aneurysms is feasible and associated with good clinical and anatomical results. The A1 aneurysm catheterization is challenging because of its small size and its superior location. [6] In these cases, the microcatheter could not safely be placed or stabilized. And because of their location, small size, and close relationship with perforators, endovascular treatment frequently requires the use of stent. [12],[13],[14],[15],[16],[17],[18] Aneurysms of the proximal ACA have three characteristics that differ from intracranial aneurysms in general: [2],[7],[9] (1) they are usually small; (2) they can arise at the origin of perforators; and (3) they are rupturing at smaller size. Because of these specific features, A1 aneurysms are technically challenging to treat. [6] There is limited data on the neurosurgical and endovascular treatment. [1],[2],[3],[4] However, in our institution, most A1 aneurysms were treated by endovascular approach. The challenging part of endovascular treatment is aneurysm catheterization because they are small and superiorly located, a few millimeters after ICA bifurcation: [6],[19] in this situation, the microcatheter guidewire is inferiorly directed to enter A1 origin and, then, it must immediately be turned in the opposite direction to enter the aneurysm. This maneuver is stressful, risky, and sometimes impossible. In order to safely catheterize A1 aneurysms, the microcatheter tip should be shaped in "S". This shape matches the anatomical structure of ICA bifurcation and A1 segment and facilitates aneurysm catheterization, stabilize the microcatheter, and decrease the risks in case of perforation. If a stent is needed and the aneurysm is small, we usually navigate a microcatheter priorly to stent deployment. The stent can stabilize the microcatheter, eliminate protrusion of coils and protect perforator at the neck. [18] In our experience, these adjunctive techniques were mandatory to treat most of the A1 aneurysms. Despite the frequent use of these techniques, none of out patients had any post-procedural neurological deficits, highlighting the safety of endovascular treatment. Moreover, anatomical results were satisfying and stable in all the followed up patients. Therefore, our series suggests that endovascular treatment can be proposed as an alternative therapeutic option for the management of A1 aneurysms. The follow-up results in this series were rather for a short follow-up time, and longer follow-up would be needed to see the long term effect of the treatment.

 
 » References Top

1.Czepko R, Libionka W, Lopatka P. Characteristics and surgery of aneurysms of the proximal (A1) segment of the anterior cerebral artery. J Neurosurg Sci 2005;49:85-95.  Back to cited text no. 1  [PUBMED]    
2.Dashti R, Hernesniemi J, Lehto H, Niemelδ M, Lehecka M, Rinne J, et al. Microneurosurgical management of proximal anterior cerebral artery aneurysms. Surg Neurol 2007;68:366-77.  Back to cited text no. 2      
3.Handa J, Nakasu Y, Matsuda M, Kyoshima K. Aneurysms of the proximal anterior cerebral artery. Surg Neurol 1984;22:486-90.  Back to cited text no. 3  [PUBMED]    
4.Hino A, Fujimoto M, Iwamoto Y, Oka H, Echigo T. Surgery of proximal anterior cerebral aneurysms. Acta Neurochir (Wien) 2002;144:1291-6.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Locksley HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. J Neurosurg 1966;25:215-39.  Back to cited text no. 5      
6.Lubicz B, Bruneau M, Dewindt A, Lefranc F, Balιriaux D, De Witte O. Endovascular treatment of proximal anterior cerebral artery aneurysms. Neuroradiology 2009;51:99-102.  Back to cited text no. 6      
7.Suzuki M, Onuma T, Sakurai Y, Mizoi K, Ogawa A, Yoshimoto T. Aneurysms arising from the proximal (A1) segment of the anterior cerebral artery, a study of 38 cases. J Neurosurg 1992;76:455-8.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Wakabayashi T, TAmaki N, Yamashita H, Saya H, Suyama T, Matsumoto S. Angiographic classification of aneurysms of the horizontal segment of the anterior cerebral artery. Surg Neurol 1985;24:31-4.  Back to cited text no. 8  [PUBMED]    
9.Wnibushi M, Kurokawa Y, Ishiguro M, Fujishige M, Inaba K. Characteristics of aneurysms arising from the horizontal portion of the anterior cerebral artery. Surg Neurol 2001;55:148-54.  Back to cited text no. 9      
10.Lv M, Lv X, Li Y, Jiang C, Jiang P, Wu Z. Dissecting aneurysm at proximal anterior cerebral artery treated by parent artery occlusion. Interv Neuroradiol 2009;15:123-6.  Back to cited text no. 10      
11.Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet 1975;1:480-4.  Back to cited text no. 11  [PUBMED]    
12.Lv M, Lv X, Li Y, Yang X, Wu Z. Vertebral dissecting aneurysm treated with the Wingspan stent deployment and detachable coils: Technical note. Interv Neuroradiol 2009;15:113-6.  Back to cited text no. 12      
13.Lubicz B, Leclerc X, Gauvrit JY, Lejeune JP, Pruvo JP. Hyperform remodelling-balloon for endovascular treatment of wide-neck intracranial aneurysms. AJNR Am J Neuroradiol 2004;25:1381-3.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Lubicz B, Lefranc F, Levivier M, Dewitte O, Pirotte B, Brotchi J, et al. Endovascular treatment of intracranial aneurysms with a branch arising from the sac. AJNR Am J Neuroradiol 2006;27:142-7.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Lv X, Li Y, Liu A, Wu Z. Endovascular management of multiple cerebral aneurysms in acute subarachnoid hemorrhage associated with fenestrated basilar artery: A case report and review of the literature. Neuroradiol J 2008;21:137-42.  Back to cited text no. 15      
16.Moret J, Pierot L, Boulin A, Castaings L. "Remodelling" of the arterial wall of the parent vessel in the endovascular treatment of intracranial aneurysms. Neuroradiology 1994;36:S83.  Back to cited text no. 16      
17.Wu Z, Lv X, Yang X, He H. Ruptured vertebro-inferoposterior cerebellar artery dissecting aneurysm treated with the Neuroform stent deployment and vertebral artery occlusion. Eur J Radiol Extra 2009;70:e100-3.  Back to cited text no. 17      
18.Zhang J, Lv X, Jiang C, Li Y, Yang X, Wu Z. Endovascular treatment of cerebral aneurysms with the use of stents in small cerebral vessels. Neurol Res 2010;32:119-22.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Moret J, Ross I, Weill A, Piotin M. The retrograde approach: A consideration for the endovascular treatment of aneurysms. AJNR Am J Neuroradiol 2000;21:262-8.  Back to cited text no. 19      


    Figures

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    Tables

  [Table 1]

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