Abstract
A 72-year-old female patient suddenly lost consciousness due to a subarachnoid hemorrhage (SAH) and a large intracerebral hematoma (ICH) stemming from the rupture of an aneurysm on the small anterior communicating artery (AcomA). The poor clinical condition of the patient meant that the ICH needed to be surgically removed. The small wide-necked aneurysm was not suitable for coil occlusion. Since there was no escaping surgery, the decision was made to also clip the aneurysm. As the aneurysm was hidden on the posterior wall of the AcomA and therefore not actually visible during the operation, a fenestrated clip was used. CTA following the operation confirmed that this had completely obliterated the aneurysm while leaving the afferent and efferent vessels patent. When the patient was referred on to a rehabilitation facility, she was awake, aphasic, and with no motor deficit. Most ruptured anterior communicating artery (AcomA) aneurysms are nowadays eliminated by endovascular therapy. However, in selected cases in which the aneurysm is not suitable for endovascular therapy, surgical clipping is the suggested route. In this chapter, we address the surgical approach, the as yet unsolved issue of which side to approach from, and radiological follow-up for ruptured AcomA aneurysms which have been microsurgically clipped. Microsurgical clipping of ruptured AcomA aneurysms is the main topic of this chapter.
This is a preview of subscription content, log in via an institution.
References
Abdulazim A, Rubbert C, Reichelt D, Mathys C, Turowski B, Steiger HJ, Hänggi D, Etminan N. Dual- versus single-energy CT-angiography imaging for patients undergoing intracranial aneurysm repair. Cerebrovasc Dis. 2017;43(5–6):272–82. https://doi.org/10.1159/000464356.
Brock M, Dietz H. The small frontolateral approach for the microsurgical treatment of intracranial aneurysms. Neurochirurgia (Stuttg). 1978;21(6):185–91. https://doi.org/10.1055/s-0028-1090343.
Chehrazi BB. A temporal transsylvian approach to anterior circulation aneurysms. Neurosurgery. 1993;33(1):172.
Crowell RM, Morawetz RB. The anterior communicating artery has significant branches. Stroke. 1977;8(2):272–3.
David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg. 1999;91(3):396–401. https://doi.org/10.3171/jns.1999.91.3.0396.
de Souza JM, Rodrigues FF, da Silva MR, Maron R, Martins L, do Souto AA, Lima LS. Cranio-orbital approach for the paraclinoidal and anterior communicating aneurysms. Arq Neuropsiquiatr. 1995;53(3-B):592–7.
Dehdashti AR, Binaghi S, Uske A, Regli L. Comparison of multislice computerized tomography angiography and digital subtraction angiography in the postoperative evaluation of patients with clipped aneurysms. J Neurosurg. 2006;104(3):395–403. https://doi.org/10.3171/jns.2006.104.3.395.
Del Maestro RF. Origin of the drake fenestrated aneurysm clip. J Neurosurg. 2000;92(6):1056–64. https://doi.org/10.3171/jns.2000.92.6.1056.
Dolati P, Eichberg D, Wong JH, Goyal M. The utility of dual-energy computed tomographic angiography for the evaluation of brain aneurysms after surgical clipping: a prospective study. World Neurosurg. 2015;84(5):1362–71. https://doi.org/10.1016/j.wneu.2015.06.027.
Fujitsu K, Kuwabara T. Orbitocraniobasal approach for anterior communicating artery aneurysms. Neurosurgery. 1986;18(3):367–9. https://doi.org/10.1227/00006123-198603000-00023.
Harland SP, Hussein A, Gullan RW. Modification of the standard pterional approach for aneurysms of the anterior circle of Willis. Br J Neurosurg. 1996;10(2):149–53. discussion 153
Horikoshi T, Nukui H, Mitsuka S, Kaneko M. Partial resection of the gyrus rectus in pterional approach to anterior communicating artery aneurysms. Neurol Med Chir (Tokyo). 1992;32(3):136–9.
Jabbarli R, Pierscianek D, Wrede K, Dammann P, Schlamann M, Forsting M, Müller O, Sure U. Aneurysm remnant after clipping: the risks and consequences. J Neurosurg. 2016;125(5):1249–55. https://doi.org/10.3171/2015.10.JNS151536.
Kempe LG, VanderArk GD. Anterior communicating artery aneurysms. Gyrus rectus approach. Neurochirurgia (Stuttg). 1971;14(2):63–70. https://doi.org/10.1055/s-0028-1090556.
Poletti CE. A temporal approach to anterior communicating artery aneurysms. Tech Note J Neurosurg. 1989;71(1):144–6. https://doi.org/10.3171/jns.1989.71.1.0144.
Smith RR, Al-Mefty O, Middleton TH. An orbitocranial approach to complex aneurysms of the anterior circulation. Neurosurgery. 1989;24(3):385–91. https://doi.org/10.1227/00006123-198903000-00013.
Steiger HJ, Schmid-Elsaesser R, Stummer W, Uhl E. Transorbital keyhole approach to anterior communicating artery aneurysms. Neurosurgery. 2001;48(2):347–51.. discussion 351-2
Suzuki M, Fujisawa H, Ishihara H, Yoneda H, Kato S, Ogawa A. Side selection of pterional approach for anterior communicating artery aneurysms–surgical anatomy and strategy. Acta Neurochir. 2008;150(1):31–9. discussion 39. https://doi.org/10.1007/s00701-007-1466-9.
Tsutsumi K, Shiokawa Y, Sakai T, Aoki N, Kubota M, Saito I. Venous infarction following the interhemispheric approach in patients with acute subarachnoid hemorrhage. J Neurosurg. 1991;74(5):715–9. https://doi.org/10.3171/jns.1991.74.5.0715.
Vincentelli F, Lehman G, Caruso G, Grisoli F, Rabehanta P, Gouaze A. Extracerebral course of the perforating branches of the anterior communicating artery: microsurgical anatomical study. Surg Neurol. 1991;35(2):98–104.
Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol. 1975;3(1):7–14.
Zabramski JM, Kiriş T, Sankhla SK, Cabiol J, Spetzler RF. Orbitozygomatic craniotomy. Tech Note J Neurosurg. 1998;89(2):336–41. https://doi.org/10.3171/jns.1998.89.2.0336.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Nature Switzerland AG
About this entry
Cite this entry
Petridis, A.K., van Lieshout, J.H., Steiger, H.J. (2019). Anterior Communicating Artery Aneurysm: Subarachnoid and Intracerebral Hemorrhage from an Aneurysm on the Posterior Aspect of the Anterior Communicating Artery – Microsurgical Clipping with a Fenestrated and Angulated Clip Without Direct Visual Control During Clip Application. In: Henkes, H., Lylyk, P., Ganslandt, O. (eds) The Aneurysm Casebook. Springer, Cham. https://doi.org/10.1007/978-3-319-70267-4_103-1
Download citation
DOI: https://doi.org/10.1007/978-3-319-70267-4_103-1
Received:
Accepted:
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-70267-4
Online ISBN: 978-3-319-70267-4
eBook Packages: Springer Reference MedicineReference Module Medicine