Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 6, 2010, pp. 968-970

Neurology India, Vol. 58, No. 6, November-December, 2010, pp. 968-970

Letter to Editor

Multiple aneurysms of distal anterior cerebral artery associated with a cerebral arteriovenous malformation

Mei Han Xue¹, Hui Wang Chun², Jin Li³, Yan Liu Song¹

¹ Department of Neurology, China-Japan Union Hospital of Jilin, Jilin, China
² Department of Neurosurgery, Jilin Provincial Hospital, Changchun, Jilin, China
³ Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
Correspondence Address: Yan Liu Song, Department of Neurology, China-Japan Union Hospital of Jilin, Jilin, China, songyanliu2010@163.com

Date of Acceptance: 22-Jul-2010

Code Number: ni10277

PMID: 21150079
DOI: 10.4103/0028-3886.73777

Sir,

A 56-year-old man was admitted to our hospital after a sudden onset of severe headaches associated with nausea and vomiting. On admission, he was conscious and complained of severe headaches. Neurological examination showed no abnormalities except for marked nuchal rigidity. A cranial computed tomography (CT) scan revealed a right frontal hematoma with intraventricular extension and subarachnoid hemorrhage [Figure - 1]. CT angiography (CTA) of the head demonstrated four aneurysms of the right distal anterior cerebral artery (DACA) [Figure - 2]a and a frontal arteriovenous malformation (AVM) [Figure - 2]b. Two aneurysms were located on the right A2 segment, the third was small and located on the orbitofrontal artery (OFR), and the fourth aneurysm was large and irregular and located on the feeding vessel of the AVM (frontopolar artery, FPA). Digital subtraction angiography (DSA) demonstrated the frontal AVM was fed by the right FPA and also the ophthalmic artery [Figure - 2]c and drained into the superior sagittal sinus (SSS) through an enlarged frontal vein [Figure - 2]d, and the multiple DACA aneurysms. The patient underwent a right frontal parasagittal craniotomy for clipping of the aneurysms and excision of the AVM through the interhemisphere approach. The right hemisphere was retracted, and an aneurysm (15×7 mm) arising from the FPA was identified [Figure - 3]a. Intraoperative indocyanine green angiography demonstrated the aneurysm, the AVM, feeding artery and draining vein [Figure - 3]b. For the aneurysm, neck was incorporated into the FPA; neck clipping was impossible, so we carefully occluded the proximal segment of the FPA adjacent to the aneurysmal neck and excised the aneurysm. Removal of the hematoma and dissection around the AVM was carried out, and an AVM measuring 3×4×4 cm was excised completely. During dissection, three aneurysms were identified-two were located on the A2 segment of the right DACA and one was originated from the OFR [Figure - 3]c. The aneurysms were clipped completely without strangulation or occlusion of the parent arteries [Figure - 3]d. The postoperative course was uneventful. Follow-up angiography performed at 3 months revealed successful obliteration of all aneurysms and total AVM excision together with patency of the major vessels [Figure - 4]. The patient recovered well without any neurological deficit.

Multiple aneurysms of DACA are relatively rare. ^[1] The occurrence of multiple DACA aneurysms and an AVM in the location of DACA has not been previously reported. In our patient, occurrence of four right DACA aneurysms and a frontal AVM fed by the right DACA was found and treated successfully. The most common presentation in patients with coexistence of aneurysms and AVMs is subarachnoid hemorrhage. Treatment is dependent upon the determination of which abnormality was the source of bleeding. Surgical therapy is considered and is directed toward the symptomatic lesion. When possible, both abnormalities should be dealt with under the same approach. ^[2],[3] Batjer et al.^[4] suggest that excision of the AVM with clipping of the feeding arteries causes the increase of pressure on the feeder artery and increases the risk of rupture. They therefore suggest the proximal aneurysms should be clipped before the excision of the AVM. Other authors argue that restoration of the normal blood flow by AVM extirpation will result in aneurysm regression and facilitate the approach. ^[5] In our case, the source of hemorrhage was the frontal AVM; therefore, surgery was directed initially towards occlusion of the feeding artery and obliteration of the AVM, which facilitated the exposure of the proximal aneurysms with less retraction. Clipping of the proximal unruptured aneurysms was the secondary objective. The results of surgical therapy for aneurysms of DACA are favorable. ^[6],[7],[8] Definitive treatment of the DACA aneurysm associated with an AVM is sometimes complex, especially for multiple aneurysms. So, when the two anomalies exist simultaneously, careful individual consideration is required to optimize surgical outcome.

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