Azygos type trilobed saccular aneurysm of anterior cerebral artery: case report
DOI:
https://doi.org/10.59156/revista.v39i01.553Keywords:
Aneurysm, Anterior cerebral artery, Clipping, MicrosurgeryAbstract
Background: the azygos-type anatomical variant of the anterior cerebral artery (ACAa) results from the confluence of both A1 and A2 segments. This anatomical variant is rare (0.2-4% prevalence) and is associated with a high incidence of aneurysms (13-71%).
Objective: to report the first case in our country of a ruptured trilobed saccular aneurysm of the ACAa successfully treated with microsurgical clipping.
Case description: a 47-year-old male with no relevant medical history presented with hypertensive crisis, drowsiness, slurred speech, Glasgow Coma Scale (GCS) score of 12/15, bilateral papilledema, and paraparesis (Daniels 4/5). Cerebral CT-angiography revealed a subarachnoid hemorrhage (Fisher grade 3), bilateral frontal hematoma, cerebral edema, and a trilobed saccular aneurysm of the ACAa.
Surgery: a bifrontal craniotomy with an interhemispheric approach was performed, including hematoma drainage and definitive aneurysm clipping. The patient was admitted to the intensive care unit intubated (WFNS grade I) and was discharged without neurological deficits (GCS 15/15). Follow-up at 15 days, 6 months, and 12 months (GOS-E: 8) confirmed complete aneurysm exclusion with proper clip positioning and preserved vascular patency.
Conclusion: the primary surgical challenge was preserving arterial flow after ACAa bifurcation to prevent neurological deficits. Microsurgical clipping provided definitive treatment with excellent clinical outcomes.
Downloads
References
López-Sala P, Alberdi N, Mendigaña M, Bacaicoa MC, Cabada T. Anatomical variants of anterior communicating artery complex. A study by computerized tomographic angiography. J Clin Neurosci, 2020; 80: 182–7. Doi: http://dx.doi.org/10.1016/j.jocn.2020.08.019.
Rhoton AL Jr. Rhoton’s cranial anatomy and surgical approaches. New York, NY: Oxford University Press; 2020.
Osborn AG. Diagnostic Cerebral Angiography. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 1998.
Krings T, Geibprasert S, Cruz JP, terBrugge KG (eds.) Neurovascular Anatomy in Interventional Neuroradiology. Stuttgart: Georg Thieme Verlag; 2015.
Auguste KI, Ware ML, Lawton MT. Nonsaccular aneurysms of the azygos anterior cerebral artery. Neurosurg Focus, 2004; 17(5): E12. Doi: 10.3171/foc.2004.17.5.12.
Singh H, Dhandapani S, Mathuriya SN. Types of azygos distal anterior cerebral artery branching patterns: Relevance in aneurysmal surgery. Cureus, 2016; 8(7):e 681. Doi: 10.7759/cureus.681.
Baptista AG. Studies on the arteries of the brain. Ii. The anterior cerebral artery: Some anatomic features and their clinical implications. Neurology, 1963; 13(10): 825–35. Disponible en: http://dx.doi.org/10.1212/wnl.13.10.825.
Reyes-Soto G, Pérez-Cruz J, Delgado-Reyes L, Ortega-Gutiérrez C, Téllez-Palacios D. Asociación de tres variantes anatómicas de circulación cerebral anterior. Cir Cir, 2012; 80(4): 333–8. Disponible en: https://www.redalyc.org/articulo.oa?id=66224459005.
Gunnal SA, Wabale RN, Farooqui MS. Variations of anterior cerebral artery in human cadavers. Neurol Asia, 2013; 18: 249–59.
Beyhan M, Gökçe E, Karakuş K. Radiological classification of azygos anterior cerebral artery and evaluation of the accompanying vascular anomalies. Surg Radiol Anat, 2020; 42(11): 1345–54. Doi: https://doi.org/10.1007/s00276-020-02509-4
Kiyofuji S, Sora S, Graffeo CS, Perry A, Link MJ. Anterior interhemispheric approach for clipping of subcallosal distal anterior cerebral artery aneurysms: case series and technical notes. Neurosurg Rev, 2020; 43(2): 801–6. Doi: http://dx.doi.org/10.1007/s10143-019-01126-z.
Platas M, Sáez M, Lambre J. Aneurismas de la arteria cerebral anterior distal. Revisión de 17 casos operados. Rev Argen Neurocir, 2007; 21(4). Disponible en: https://aanc.org.ar/ranc/items/show/431.
