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Table of Contents    
LETTER TO EDITOR
Year : 2010  |  Volume : 58  |  Issue : 6  |  Page : 968-970

Multiple aneurysms of distal anterior cerebral artery associated with a cerebral arteriovenous malformation


1 Department of Neurology, China-Japan Union Hospital of Jilin, Jilin, China
2 Department of Neurosurgery, Jilin Provincial Hospital, Changchun, Jilin, China
3 Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China

Date of Acceptance22-Jul-2010
Date of Web Publication10-Dec-2010

Correspondence Address:
Yan Liu Song
Department of Neurology, China-Japan Union Hospital of Jilin, Jilin
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.73777

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How to cite this article:
Xue MH, Chun HW, Li J, Song YL. Multiple aneurysms of distal anterior cerebral artery associated with a cerebral arteriovenous malformation. Neurol India 2010;58:968-70

How to cite this URL:
Xue MH, Chun HW, Li J, Song YL. Multiple aneurysms of distal anterior cerebral artery associated with a cerebral arteriovenous malformation. Neurol India [serial online] 2010 [cited 2021 Dec 3];58:968-70. Available from: https://www.neurologyindia.com/text.asp?2010/58/6/968/73777


Sir,

A 56-year-old man was admitted to our hospital after a sudden onset of severe headaches associated with nausea and vomiting. On admission, he was conscious and complained of severe headaches. Neurological examination showed no abnormalities except for marked nuchal rigidity. A cranial computed tomography (CT) scan revealed a right frontal hematoma with intraventricular extension and subarachnoid hemorrhage [Figure 1]. CT angiography (CTA) of the head demonstrated four aneurysms of the right distal anterior cerebral artery (DACA) [Figure 2]a and a frontal arteriovenous malformation (AVM) [Figure 2]b. Two aneurysms were located on the right A2 segment, the third was small and located on the orbitofrontal artery (OFR), and the fourth aneurysm was large and irregular and located on the feeding vessel of the AVM (frontopolar artery, FPA). Digital subtraction angiography (DSA) demonstrated the frontal AVM was fed by the right FPA and also the ophthalmic artery [Figure 2]c and drained into the superior sagittal sinus (SSS) through an enlarged frontal vein [Figure 2]d, and the multiple DACA aneurysms. The patient underwent a right frontal parasagittal craniotomy for clipping of the aneurysms and excision of the AVM through the interhemisphere approach. The right hemisphere was retracted, and an aneurysm (15×7 mm) arising from the FPA was identified [Figure 3]a. Intraoperative indocyanine green angiography demonstrated the aneurysm, the AVM, feeding artery and draining vein [Figure 3]b. For the aneurysm, neck was incorporated into the FPA; neck clipping was impossible, so we carefully occluded the proximal segment of the FPA adjacent to the aneurysmal neck and excised the aneurysm. Removal of the hematoma and dissection around the AVM was carried out, and an AVM measuring 3×4×4 cm was excised completely. During dissection, three aneurysms were identified-two were located on the A2 segment of the right DACA and one was originated from the OFR [Figure 3]c. The aneurysms were clipped completely without strangulation or occlusion of the parent arteries [Figure 3]d. The postoperative course was uneventful. Follow-up angiography performed at 3 months revealed successful obliteration of all aneurysms and total AVM excision together with patency of the major vessels [Figure 4]. The patient recovered well without any neurological deficit.
Figure 1: Computed tomographic scan of the head demonstrating a right frontal intraparenchymal hematoma with intraventricular extension and subarachnoid hemorrhage

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Figure 2: Computed tomographic angiograms with 3-dimensional reconstruction, anteroposterior view (a) and lateral view (b) showing four aneurysms (white arrows) and a frontal AVM (black arrow). Right internal carotid artery angiograms, arterial phase (c) and venous phase (d) showing four aneurysms of DACA and a frontal AVM fed by the frontopolar artery and ophthalmic artery, and venous drainage into the superior sagittal sinus through a dilated frontal vein

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Figure 3: Intraoperative photography showing right frontopolar artery aneurysm and dilated drainage vein (a) the finding is confirmed by intraoperative indocyanine green angiography (b). The other three aneurysms are seen before clipping (c) and after clipping (d). Aneurysm- (AN), A1 segment of right anterior cerebral artery- (RA1), A2 segment of right anterior cerebral artery- (RA2), distal frontopolar artery- (DFPA), draining vein- (DV), feeding artery- (FA), proximal frontopolar artery- (PFPA), right internal carotid artery- (RICA), right olfactory nerve- (ROL), right optic nerve- (ROP)

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Figure 4: Postoperative angiogram of the right internal carotid artery showing complete obliteration of all aneurysms and AVM with patency of the major vessels

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Multiple aneurysms of DACA are relatively rare. [1] The occurrence of multiple DACA aneurysms and an AVM in the location of DACA has not been previously reported. In our patient, occurrence of four right DACA aneurysms and a frontal AVM fed by the right DACA was found and treated successfully. The most common presentation in patients with coexistence of aneurysms and AVMs is subarachnoid hemorrhage. Treatment is dependent upon the determination of which abnormality was the source of bleeding. Surgical therapy is considered and is directed toward the symptomatic lesion. When possible, both abnormalities should be dealt with under the same approach. [2],[3] Batjer et al.[4] suggest that excision of the AVM with clipping of the feeding arteries causes the increase of pressure on the feeder artery and increases the risk of rupture. They therefore suggest the proximal aneurysms should be clipped before the excision of the AVM. Other authors argue that restoration of the normal blood flow by AVM extirpation will result in aneurysm regression and facilitate the approach. [5] In our case, the source of hemorrhage was the frontal AVM; therefore, surgery was directed initially towards occlusion of the feeding artery and obliteration of the AVM, which facilitated the exposure of the proximal aneurysms with less retraction. Clipping of the proximal unruptured aneurysms was the secondary objective. The results of surgical therapy for aneurysms of DACA are favorable. [6],[7],[8] Definitive treatment of the DACA aneurysm associated with an AVM is sometimes complex, especially for multiple aneurysms. So, when the two anomalies exist simultaneously, careful individual consideration is required to optimize surgical outcome.

 
  References Top

1.Lehecka M, Porras M, Dashti R, Niemela M, Hernesniemi J. Anatomic features of distal anterior cerebral artery aneurysms: A detailed angiographic analysis of 101 patients. Neurosurgery 2008;63:219-29.   Back to cited text no. 1
    
2.Heros RC. The management of patients with arteriovenous malformations and associated intracranial aneurysms. Neurosurgery 1998;43:202-11.  Back to cited text no. 2
    
3.Thompson RC, Steinberg GK, Levy RP, Marks MP. The management of patients with arteriovenous malformations and associated intracranial aneurysms. Stroke 1998;29:2669-70.  Back to cited text no. 3
    
4.Batjer H, Suss R, Samson D. Intracranial arteriovenous malformations associated with aneurysms. Neurosurgery 1986;18:29-35.  Back to cited text no. 4
    
5.Kondziolka D, Nixon BJ, Lasjaunias P, Tucker WS, TerBrugge K, Spiegel SM. Cerebral arteriovenous malformations with associated arterial aneurysms: Hemodynamic and therapeutic considerations. Can J of Neurol Sci 1988;15:130-4.  Back to cited text no. 5
    
6.Lee JW, Lee KC, Kim YB, Huh SK. Surgery for distal anterior cerebral artery aneurysms. Surg Neurol 2008;70:153-9.  Back to cited text no. 6
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7.Lehecka M, Niemela M, Seppanen JM, Lehto H, Koivisto T, Ronkainen A, et al. No long-term excess mortality in 280 patients with ruptured distal anterior cerebral artery aneurysms. Neurosurgery 2007;60:235-41.  Back to cited text no. 7
    
8.Lehecka M, Lehto H, Niemela M, Juvea S, Dashti R, Koivisto T, et al. Distal anterior cerebral artery aneurysms: Treatment and outcome analysis of 501 patients. Neurosurgery 2008;62:590-601.  Back to cited text no. 8
    


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