Anterior Communicating Artery Aneurysm: Large Aneurysm, Mass Effect, Deconstructive Techniques and Coiling, Occlusion, Mass Effect Relief and Excellent Evolution

Abstract

A large anterior communicating artery (AcomA) aneurysm was treated by deconstructive techniques and intrasaccular coil occlusion in two stages. A 57-year-old woman presented with a history of chronic headaches that had been substantially aggravated in the last three weeks with associated nausea, general discomfort, slow mentation, episodes of right eye amaurosis, and even confusion. Her admission neurological evaluation also strongly suggested that she suffered seizures, although this could not be shown definitively. CT followed by MRI confirmed the presence of a large-to-giant (23 mm) AcomA aneurysm with significant perilesional edema and associated mass effect. Diagnostic cerebral angiography confirmed that the aneurysm arose from a wide neck involving the right A1-A2 junction and preferentially filled through the right internal carotid artery (ICA). It was irregularly shaped and pointed to the left side. A midsized aneurysm of the right paraophthalmic ICA was also identified. A left ICA angiogram demonstrated the presence of a patent AcomA and spontaneous crossflow. In the first-stage intervention, the right distal A1 segment was deliberately and focally occluded with coils at a point in close proximity to the aneurysm’s origin. This arterial segment is usually devoid of perforating branches. In the second procedure, performed two weeks later, the remnant of the aneurysm was embolized through an approach via the left ICA and across the AcomA. Although the patient showed rapid clinical improvement and MRI showed resolution of the mass effect, she still experienced episodic right eye visual obscuration and felt unable to return to teaching. In a third intervention, performed three years later, a flow-diverter stent was implanted across the right paraophthalmic ICA aneurysm. The patient experienced a surprising disappearance of her visual problems. This case reaffirms the validity and efficacy of deconstructive techniques in the management of selected cases of AcomA aneurysms.