Advertisement

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

  • Athanasios K. PetridisEmail author
  • Jasper Hans van Lieshout
  • Hans Jakob Steiger
Living reference work entry
  • 10 Downloads

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.

Keywords

Anterior communicating artery Intracranial aneurysm Microsurgical clipping Fenestrated clip 

References

  1. 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.CrossRefPubMedGoogle Scholar
  2. 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.CrossRefGoogle Scholar
  3. Chehrazi BB. A temporal transsylvian approach to anterior circulation aneurysms. Neurosurgery. 1993;33(1):172.PubMedGoogle Scholar
  4. Crowell RM, Morawetz RB. The anterior communicating artery has significant branches. Stroke. 1977;8(2):272–3.CrossRefGoogle Scholar
  5. 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.CrossRefPubMedGoogle Scholar
  6. 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.CrossRefGoogle Scholar
  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.CrossRefPubMedGoogle Scholar
  8. 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.CrossRefPubMedGoogle Scholar
  9. 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.CrossRefPubMedGoogle Scholar
  10. 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.CrossRefPubMedGoogle Scholar
  11. 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 153CrossRefGoogle Scholar
  12. 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.CrossRefGoogle Scholar
  13. 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.CrossRefPubMedGoogle Scholar
  14. 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.CrossRefPubMedGoogle Scholar
  15. 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.CrossRefGoogle Scholar
  16. 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.CrossRefPubMedGoogle Scholar
  17. Steiger HJ, Schmid-Elsaesser R, Stummer W, Uhl E. Transorbital keyhole approach to anterior communicating artery aneurysms. Neurosurgery. 2001;48(2):347–51.. discussion 351-2PubMedGoogle Scholar
  18. 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.CrossRefPubMedGoogle Scholar
  19. 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.CrossRefPubMedGoogle Scholar
  20. 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.CrossRefGoogle Scholar
  21. Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol. 1975;3(1):7–14.PubMedGoogle Scholar
  22. 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.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Athanasios K. Petridis
    • 1
    Email author
  • Jasper Hans van Lieshout
    • 1
  • Hans Jakob Steiger
    • 1
  1. 1.Department of NeurosurgeryHeinrich Heine UniversityDüsseldorfGermany

Personalised recommendations