PMC3205492_01
Follow-up images of the aneurysm. (a) Axial computed tomography scan before the first operation in 2003 showing a 15-mm heterogeneous mass in the left frontal lobe. (b) Axial computed tomography scan on admission in 2010 showing a 28-mm giant aneurysm with perifocaledema. The aneurysm is growing up with calcification. (c) Preoperative axial T2-weighted magnetic resonance imaging showing clear high signal intensity of marked perifocaledema in the white matter around the aneurysm. (d) The anteroposterior view of preoperative 3-dimensional computed tomography angiography showing three aneurysms, including a distal anterior cerebral artery aneurysm, an anterior communicating artery aneurysm (short arrow) and a right middle cerebral artery aneurysm (long arrow). (e) The left oblique view of preoperative 3-dimensional digital subtraction angiography of the left internal carotid artery showing the aneurysm at the pericallosal artery (PerA, short arrow)-callosomarginal artery (CMA, long arrow) junction
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F1
August 2003, a 69-year-old female who had hypertension and an abdominal aortic aneurysm complained of dizziness. A computed tomography (CT) scan showed a 15-mm heterogeneous mass in the cerebral left frontal lobe [Figure 1a]. A CT scan [Figure 1b] and magnetic resonance imaging [Figure 1c] showed a 28-mm giant aneurysm with severe calcification and perifocaledema. Three-dimensional CT angiography (3D-CTA) [Figure 1d] and three-dimensional digital subtraction angiography (DSA) of the left internal carotid artery (ICA) [Figure 1e] demonstrated that the aneurysm was located at the left PerA-CMA junction.
Illustrations showing four possible surgical strategies. Reconstruction for the left distal PerA was to be decided during operation. (b) Shows the reconstructive procedure for the left distal PerA, and (c) and (d) show the surgical strategies requiring no reconstruction. (a) Neck clipping. (b) Left A2 trapping plus A3-A3 side-to-side anastomosis with reconstruction of the left distal PerA by right CMA-left distal PerA side-to-end anastomosis. (c) Left A2 trapping plus bonnet bypass using a short graft of the right superficial temporal artery. (d) Aneurysm resection plus proximal PerA-CMA end-to-end anastomosis
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F2
Standard neck clipping [Figure 2a] seemed difficult because of severe calcification, similar to that observed in the previous operation. Therefore, three possible strategies were considered for bypass surgery before operation [Figure 2b-d]. Therefore, aneurysm resection and proximal PerA-CMA end-to-end anastomosis [Figure 2c] were performed [Figure 3c].
Intraoperative photographs taken during the interhemispheric approach. (a) A yellowish solid aneurysm (box) at the left PerA (short arrow)-CMA (long arrow) junction. (b) Thrombectomy of the aneurysm while trapping the aneurysm after cutting the left distal PerA. The neck of the aneurysm is highly calcified. (c) Left proximal PerA-CMA end-to-end anastomosis
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F3
The aneurysm was yellowish and solid because of severe calcification [Figure 3a].The left distal PerA was running behind the aneurysm and was densely adherent to the aneurysm because of fibrosis from the previous wrapping operation and could not therefore be dissected from the aneurysm. After removal of the thrombus, three lumens were visualized in the aneurysm [Figure 3b]. Therefore, aneurysm resection and proximal PerA-CMA end-to-end anastomosis [Figure 2c] were performed [Figure 3c].
Intraoperative digital subtraction angiography of the left internal carotid artery (oblique views). (a) Left internal carotid angiogram showing the aneurysm at the left PerA (short arrow)-CMA (long arrow) junction. (b) Left internal carotid angiogram under occlusion of the left A2 segment, showing good retrograde flow to the left distal PerA (arrow) from the left middle cerebral artery through leptomeningeal anastomosis (arrow). (c) Left internal carotid angiogram after aneurysm resection and proximal PerA-CMA end-to-end anastomosis, showing elimination of the distal anterior cerebral artery aneurysm (arrow head) and good recanalization of the left CMA (arrow)
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F4
Findings from intraoperative DSA are shown in Figure 4.
Postoperative computed tomography scan and 3-dimensional CT angiography. (a) Computed tomography scan after operation showing no ischemic lesion in the left anterior cerebral artery territory. (b) The oblique view of postoperative 3-dimensional CT angiography showing elimination of the aneurysm and good recanalization of the left callosomarginal artery (arrow)
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F5
The patient had no neurological deficits after operation, and the postoperative CT scan demonstrated no infarction including the left ACA territory [Figure 5a]. Elimination of the aneurysm and good flow in the left CMA were observed on 3D-CTA [Figure 5b].The patient was doing well 6 months after operation.