Ruptured aneurysm of the distal anterior cerebral artery: clinical features and surgical strategies.
ABSTRACT Ruptured aneurysms of the distal anterior cerebral artery (ACA) are relatively rare and surgical management provides some unique technical challenges. This retrospective analysis of 20 patients with distal ACA aneurysms evaluated the clinical features and surgical strategies. The characteristic findings were small and common concurrent aneurysms, and frequent intracerebral hematoma (ICH). Aneurysms were divided by location on the genu (n = 13), infracallosal (n = 5), and supracallosal portions (n = 2). All patients except one underwent surgery via an interhemispheric route. Unilateral craniotomy was performed for aneurysms on the genu portions without massive ICH. Bilateral craniotomies were selected for aneurysm located on the infracallosal portion or combined with massive ICH. No intraoperative rupture was observed. Favorable outcomes were achieved in 15 of 20 patients, and only one patient died. The preoperative Hunt and Kosnik grade was closely correlated with the outcome.
- Neurology 11/1963; 13:825-35. · 8.25 Impact Factor
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ABSTRACT: Most distal anterior cerebral artery (ACA) aneurysms arise at the pericallosal-callosomarginal artery (PerA-CMA) junction, which is usually located in the A3 segment of the ACA around the genu of the corpus callosum. Aneurysms in the PerA-CMA junction are divided into two types according to their location: supracallosal and infracallosal. Infracallosal distal ACA aneurysms are defined as those located in the lower half of the A3 segment, which makes it more difficult to gain proximal control. In this study, the authors examined the microsurgical anatomy of the distal ACA region, focusing especially on the relationship between the PerA and CMA located in the lower half of the A3 (infracallosal) segment, and present a surgical strategy for dealing with distal ACA aneurysms. The microsurgical anatomy of the distal ACA region was examined in 22 adult cadaveric cerebral hemispheres after perfusion of the arteries and veins with colored silicone. The relationships of the infracallosal segment of the PerA to the CMA and the A2 segment of the PerA to the frontopolar artery were examined. The distance between the nasion and the site at which a parallel line directed along the long axis of the infracallosal PerA just proximal to the origin of the CMA artery crosses the forehead (which we have named the PC point) was also measured. Surgical approaches to distal ACA aneurysms were examined in stepwise dissections. The PerA-CMA junctions were located in the supracallosal and infracallosal segments of A3 in 36 and 55% of cases, respectively. In the infracallosal region, it was difficult to identify the proximal PerA and to establish proximal control of the vessel. The infracallosal part of the proximal PerA coursed almost parallel to the frontal cranial base, and the PC point was 42.2 +/- 15.9 mm (mean +/- standard deviation) from the nasion. These findings indicate that there is only a limited space in which to access an infracallosal distal ACA aneurysm below the PC point and establish proximal control by the anterior interhemispheric approach. When the approach is made above the PC point, an anterior callosotomy may be necessary to establish proximal control before final aneurysm dissection and clip placement are completed. The PC point is an important surgical landmark in planning the surgical strategy for infracallosal distal ACA aneurysms.Journal of Neurosurgery 10/2003; 99(3):517-25. · 3.15 Impact Factor
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ABSTRACT: Between July 1975 and July 1985, 20 patients with 24 congenital distal anterior cerebral artery (DACA) aneurysms were admitted to our institution and underwent microsurgical clipping of their aneurysms. This group composes 4% of the 588 aneurysms managed surgically during this period. The clinical presentations included subarachnoid hemorrhage, transient ischemic attacks, headaches, and seizures. Fourteen patients had additional vascular anomalies documented by angiography: multiple aneurysms, bilateral DACA aneurysms, arteriovenous malformation distal to incidental DACA aneurysms, and azygous DACA. Computed tomography was performed in 19 patients and was valuable in preoperative planning and prognosis: intracerebral hematoma and intraventricular hemorrhage were associated with poor preoperative grade and the development of vasospasm. Operative management, case morbidity/mortality, and the high incidence of multiple aneurysms and other vascular anomalies associated with DACA aneurysms are discussed. Because of the devastating effects of subarachnoid hemorrhage from these aneurysms, they should be carefully searched for and treated before hemorrhage occurs.Neurosurgery 06/1987; 20(5):735-41. · 2.53 Impact Factor