PMC5875106_01
(a) Head computed tomography (CT) on admission. Diffuse subarachnoid hemorrhage in the basal cistern. In particular, a thick subarachnoid hemorrhage in the proximal portion of interhemispheric fissure. (b) Three-dimensional-CT Angiography (3D-CTA) on admission. 3D-CTA showed the anterior communicating artery (Acom) fenestration, but no evidence of aneurysm. The quality of this study was poor, probably due to high intracranial pressure
SNI-9-67-g001.jpg
PMC5875106_01_SNI-9-67-g001.jpg
F1
Head computed tomography (CT) revealed an extensive subarachnoid hemorrhage (SAH) filling basal cisterns, especially the thick hemorrhage in the interhemispheric fissure [Figure 1a]. CT angiography showed an Acom with fenestration, but no evidence of aneurysm [Figure 1b].
(a-d) Three-dimensional-digital subtraction angiography (3D-DSA) on admission. (a) water's view, (b) A-P view, (c) L-R view, (d) magnification picture of c. 3D-DSA revealed the vascular anomaly [the anterior communicating artery (Acom) fenestration and an accessory anterior cerebral artery] and small Acom aneurysm projecting posteriorly. An accessory anterior cerebral artery (arrow head) arose from the upper limb of the fenestrated segment. In contrast, the Acom aneurysm (arrow) arose from the inferior limb of the fenestrated segment. (e-f) Intraoperative photographs. The surgical view obtained from the interhemispheric approach showed a blind area behind the Acom complex with limited mobilization. A fenestrated clip was applied to be able to preserve an accessory anterior cerebral artery
SNI-9-67-g002.jpg
PMC5875106_01_SNI-9-67-g002.jpg
F2
Three-dimensional-digital subtraction angiography (3D-DSA) demonstrated the fenestration of Acom with a small saccular aneurysm (2 mm) [Figure 2a-d]. The aneurysm arose from the inferior limb of the fenestrated segment, and it projected posteriorly [Figure 2b-d]. In addition, an accessory ACA arose from the upper limb of the fenestrated segment [Figure 2c and d]. Acom, because we could not mobilize the Acom complex enough. Additionally, the surgical dissection behind the Acom complex was interfered by an accessory ACA [Figure 2e]. The intraoperative premature rupture occurred, and a fenestrated clip was applied to be able to preserve an accessory ACA [Figure 2f].
(a) Head computed tomography (CT) on Day 13. The focal subarachnoid hemorrhage was observed around the aneurysmal clip, suggesting the re-rupture from the remnant of anterior communicating artery (Acom) aneurysm. (b-c) Two-dimensional-digital subtraction angiography (2D-DSA) after re-rupture. b: P-A view, c: R-L view. 2D-DSA showed the recurrence of Acom aneurysm. (d) Three-dimensional-digital subtraction angiography (3D-DSA) after re-rupture, posterior view with caudal angulation. The recurrence of an aneurysm (arrow) was observed next to the clip
SNI-9-67-g003.jpg
PMC5875106_01_SNI-9-67-g003.jpg
F3
Unfortunately, the re-rupture from an Acom aneurysm occurred on Day 13 [Figure 3a-c]. 3D-DSA demonstrated the recurrence of an aneurysm next to the clip [Figure 3d].