PMC10246312_01
Preoperative computed tomography (CT) and magnetic resonance imaging. (a) Non-contrast CT, (b) CT angiography, (c) three-dimensional-CT angiography, (d) T2 weighted image, (e) fluid-attenuated inversion recovery image, (f) T2*-weighted image. A part of the aneurysm wall and the front rim of the signal change area present low intensity on T2*. (g) Source image of time-of-flight magnetic resonance angiography, (h) Maximum intensity projection image, Blood flow is observed only in a part of the aneurysm, and there is a free space on the outside showing a thrombus. T2* stands for T2 star-weighted image.
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This time, CT of the brain revealed a high-density mass and surrounding well-defined low density area in the left frontal lobe [Figure 1a]. CT angiography (CTA) revealed a partially contrasted aneurysm with an intraluminal thrombus arising from the left distal anterior cerebral artery [Figure 1b] and three-dimensional (3D)-CTA revealed a lobulated large aneurysm [Figure 1c]. Magnetic resonance imaging (MRI) also revealed the homogeneous signal change in the left frontal lobe surrounding the aneurysm, as shown by hyperintensity on T2 weighted [Figure 1d] and fluid-attenuated inversion recovery (FLAIR) image [Figure 1e] stronger than the PAE. T2 star (T2*)-weighted image [Figure 1f]. The major axis of the aneurysm including the thrombotic part was about 20 mm [Figure 1g]. MR angiography also revealed a large lobulated aneurysm [Figure 1h].
(a) Lateral view of left internal carotid artery angiogram, (b) three-dimensional digital subtraction angiography (3D-DSA) image, (c) operative view of 3D-DSA image, There is a large aneurysm at the genu portion of the left anterior cerebral artery (ACA), and a multilobular aneurysm at the genu portion of the right ACA. Both aneurysm domes are pressed together. (d-f) Intraoperative photographs during clipping of "kissing" distal ACA aneurysms. (d) Opening the space around the left thrombosed aneurysm, yellowish serous fluid was drained (black arrow). The surrounding brain parenchyma was also yellowish to indicate the presence of inflammation. (e) Multiple clips were needed to obliterate both aneurysms. Because of lack of mobility of the aneurysms and limited horizontal space, application of the clips were restricted and should be inserted along the visual axis of the surgical field. (f) Obliteration of the aneurysms and patency of the parent arteries and the branches were confirmed by venous infusion of the indocyanine green.
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Digital subtraction angiography (DSA) and 3D-DSA revealed two saccular aneurysms located at the genu portion of the bilateral anterior cerebral artery (ACA) with domes pressed together [Figures 2a-c], one with a diameter of 14 mm arising from the left ACA and the other of 5mm arising from the right ACA with blebs. Most of the left thrombosed aneurysm buried in the frontal lobe and a thin brain parenchyma attached around the neck was incised, a slight yellowish serous fluid was drained [Figure 2d]. Clips were applied to each aneurysm along the visual axis of the surgical field, and the large aneurysm on the left was a broad neck, so multiple clips were applied in parallel [Figure 2e]. Finally, obliteration of the aneurysms and patency of the parent arteries and the branches were confirmed by venous infusion of the indocyanine green [Figure 2f].
(a) Non-contrast computed tomography the day after the surgery revealed disappearance of perianeurysmal signal changes except for the perianeurysmal edema (PAE) (b) Lateral view of postoperative left internal carotid artery angiogram, (c and d) Postoperative three-dimensional digital subtraction angiography images, obliteration of the both aneurysms were confirmed. (e) T2-weighted image at 6 months after the operation, (f) fluid-attenuated inversion recovery image at 6 months after the operation, Recurrence of the image change around the aneurysm was not observed and both images showed improvement of the PAE.
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PAE [Figure 3a]. Postoperative DSA and 3D-DSA revealed obliteration of both aneurysms [Figures 3b-d]. A follow-up MRI performed 6 months after the operation showed improvement of the PAE [Figures 3e and f].