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|NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTER TO EDITOR
|Year : 2017 | Volume
| Issue : 3 | Page : 623-625
Ruptured dissecting aneurysm of the recurrent artery of Heubner: Consideration of pathological findings
Atsushi Ogata1, Shuji Sakata2, Hiroaki Okamoto1, Tatsuya Abe3
1 Department of Neurosurgery, Saga-Ken Medical Centre Koseikan; Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
2 Department of Neurosurgery, Saga-Ken Medical Centre Koseikan, Saga, Japan
3 Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
|Date of Web Publication||9-May-2017|
Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga-shi, Saga 849-8501
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ogata A, Sakata S, Okamoto H, Abe T. Ruptured dissecting aneurysm of the recurrent artery of Heubner: Consideration of pathological findings. Neurol India 2017;65:623-5
|How to cite this URL:|
Ogata A, Sakata S, Okamoto H, Abe T. Ruptured dissecting aneurysm of the recurrent artery of Heubner: Consideration of pathological findings. Neurol India [serial online] 2017 [cited 2022 Jun 29];65:623-5. Available from: https://www.neurologyindia.com/text.asp?2017/65/3/623/205882
Intracranial aneurysms of the central nervous system most commonly involve cerebral arteries comprising the circle of Willis. Peripherally located aneurysms are rare and may be associated with infection, arteriovenous malformation, moyamoya disease, granulomatous angiitis, meningovascular syphilis, or trauma., Aneurysms of the recurrent artery of Heubner (RAH) are very rare.,, To our knowledge, pathological studies on aneurysms of RAH have not been reported. We present a rare case of a ruptured aneurysm of RAH, including the pathological findings.
A 31-year old man was admitted to our hospital with complaints of sudden onset of headache and vomiting. He had no history of hypertension, previous trauma, connective tissue disorder, or sepsis. Neurological deficits were not observed.
A computed tomography (CT) scan at admission showed a diffuse subarachnoid hemorrhage with a right-sided dominant, thick clot in the basal and Sylvian cisterns [Figure 1]a. A CT angiogram (CTA) demonstrated a small aneurysm above the right anterior cerebral artery [Figure 1]a and [Figure 1]b. A right internal carotid angiogram demonstrated a small fusiform aneurysm arising from the right RAH [Figure 1]c and [Figure 1]d. There was no evidence of moyamoya-like vessels, vasculitis, or tumors, and the entire surrounding vasculature appeared normal in the four vessels studied.
|Figure 1: Images of the ruptured right recurrent artery of Heubner fusiform aneurysm. (a) Noncontrast head CT scan demonstrates diffuse subarachnoid hemorrhage with a thick clot in the right Sylvian cistern. (b)Three-dimensional CTA demonstrates a small aneurysm above the right anterior cerebral artery (A1 segment). (c and d) Preoperative right carotid angiograms (c, anteroposterior view; d, right oblique view) demonstrate the aneurysm (arrow) arising from RAH|
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The standard right pterional craniotomy was performed. RAH was followed to the superior wall of the A1 segment. A careful sharp dissection led to the fusiform aneurysm, which was dark purple and arising from RAH, with the fundus partially embedded in the frontal lobe [Figure 2]. The aneurysm was resected after trapping the parent artery.
|Figure 2: Intra-operative photograph shows the right optic nerve (ON), right internal carotid artery (IC), anterior cerebral artery (ACA), and fusiform aneurysm (asterisk) arising from the RAH (arrowheads)|
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Postoperatively, the patient had transient mild weakness of the left hand. A postoperative CT scan demonstrated a low-density area in the head of the right caudate nucleus [Figure 3]. The left-hand weakness improved within several days after the operation. On day 7, the CTA demonstrated disappearance of the fusiform aneurysm and no evidence of vasospasm. During the hospital course, the full diagnostic work-up for a possible infectious etiology and connective tissue disorders turned out to be negative.
|Figure 3: Postoperative images. Noncontrast head CT scan demonstrates a low-density area in the head of the right caudate nucleus|
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The pathological findings [Figure 4] revealed that the internal elastic lamina was well visualized along the luminal surface of the parent artery. The internal elastic lamina showed widespread disruption at the neck of the aneurysm. The aneurysm contained a luminal thrombus, and its wall was composed of adventitia and connective tissue. The aneurysmal wall lacked the internal elastic lamina.
|Figure 4: Photomicrograph of the resected aneurysm specimen shows widespread disruption of the internal elastic lamina at the neck of the aneurysm (arrows). The aneurysm (AN) contains a luminal thrombus, and its wall is composed of adventitia and connective tissue without the internal elastic lamina (elastic van Gieson stain; original magnification, ×20)|
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To our knowledge, three cases of an aneurysm of RAH have been reported, and all aneurysms had ruptured [Table 1].,, To the best of our knowledge, ours is the first report demonstrating the pathological findings of an aneurysm of RAH. Mizutani et al., classified nonatherosclerotic fusiform aneurysms into four types on the basis of pathological findings. In their study, Type 1 corresponded to classic dissecting aneurysms, the pathogenesis of which was characterized by acute widespread disruption of the internal elastic lamina without intimal thickening. On the other hand, pathological findings of true aneurysms demonstrated that the internal elastic lamina appeared thick and beaded or thin, attenuated, and reduplicated with focal fragmentation. Therefore, in our case, a ruptured aneurysm was thought to be a dissecting aneurysm. Similar to our case, most ruptured aneurysms of RAH in the prior case reports were small and fusiform [Table 1].,, This fact suggested that most previously reported aneurysms of RAH were dissecting aneurysms.
Regarding surgery for dissecting aneurysms, several investigators , have mentioned that direct “aneurysm only'' clip application is associated with a high rate of regrowth of the lesion or rebleeding caused by preserved flow in the normal half of the affected vessel, despite an excellent intraoperative aneurysmal obliteration. Therefore, they recommended proximal vessal occlusion or trapping., We considered that recommendation and performed trapping of the ruptured aneurysm of RAH. The postoperative CT scan demonstrated a low-density area in the head of the right caudate nucleus, and the patient transiently had a mild weakness of the left hand, without any permanent neurological sequelae. Sasaki et al., reported that nine patients had cerebral infarction in the territory of RAH among 1043 patients who underwent aneurysmal surgery, four patients transiently suffered mild disorientation or dementia without a permanent neurological deficit, and the other five patients were asymptomatic. To prevent ischemic complications of RAH, direct “aneurysm only'' clip application was performed in two of the three previously reported cases of RAH aneurysms and preservation of RAH was unsuccessful in one [Table 1].,, It may be difficult to preserve RAH because of its small calibre.
The origin of the aneurysm in our case was presumed to be idiopathic. A dissecting aneurysm of RAH can occur in patients without the presence of an underlying disease.
We thank Dr. Daisuke Mori at the Department of Pathology, Saga-Ken Medical Centre Koseikan, Japan for advice on the pathological findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]