Anterior Communicating Artery Aneurysm: Symptomatic Anterior Communicating Artery Aneurysms in a Patient with Autosomal Dominant Polycystic Kidney Disease, Treated with Flow Diversion

Abstract

Autosomal dominant polycystic kidney disease (ADPKD) is a renal genetic disorder associated with an increased risk of cerebral aneurysms. Other vascular abnormalities such as aortic dissection, coronary artery dissection, intracranial and extracranial supra-aortic arterial dissection, and valvular heart disease have also been reported in association with ADPKD. A 50-year-old woman with a history of ADPKD and arterial hypertension experienced an episode of sudden onset severe headaches associated with vomiting and general malaise. Over-the-counter analgesics administered at home provided partial relief, but her headache intensified 1 day later. She was admitted to a primary care hospital. A cranial CT followed by an MRI/MRA obtained 3 days after symptom onset revealed a diffuse subarachnoid hemorrhage (SAH), Fisher grade 2, and a small irregularly shaped anterior communicating artery (AcomA) aneurysm. She was transferred to our center 8 days after the diagnosis of the SAH. A non-contrast CT of the head taken at admission confirmed that cisterns were clear, and there was no hydrocephalus.

Diagnostic angiography confirmed the presence of multiple intracranial aneurysms and signs of bilateral cervical carotid artery dissections. Angiograms taken of the right internal carotid artery (ICA) followed by a rotational angiogram with 3D reconstruction showed aneurysmal dilatation of the mid-cervical third of the right ICA, a small AcomA saccular aneurysm at the posterior aspect of the AcomA, three small associated aneurysms in the AcomA complex, aneurysmal dilatation of the right middle cerebral artery (MCA) trifurcation, and a small right-hand paraclinoid ICA aneurysm, totaling seven aneurysms. An angiogram of the left ICA confirmed intermittent occlusion of this artery by a focal mid-cervical occlusive dissection. The patient was placed under general anesthesia, and a loading dose of acetylsalicylic acid (ASA) and prasugrel were administered by nasogastric tube. After confirming the dual antiplatelet effect, a single flow-diverter stent (FDS) was implanted from the left A2 to the right A1 segment across all of the AcomA complex aneurysm necks, with immediate angiographic confirmation of reduced aneurysm filling. The procedure was uneventful, and the patient was transferred to the ICU for extubation and clinical and neurological monitoring. Her clinical course was unremarkable. The pain from her headaches was successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics. Follow-up angiogram 6 days after the intervention confirmed mild vasospasm and complete exclusion of the treated aneurysms. The patient was discharged home after 7 days. Platelet inhibition was evaluated every 12 h for the first 3 days after the intervention, and the antiplatelet dose was adjusted as required. The feasibility, safety, and effectiveness of flow-diverter stents in acutely ruptured brain aneurysms in ADPKD are the main topic of this chapter.