PMC10157198_01
Preoperative CT and CTA images. (A) CT showing the extensive SAH, focusing on the left suprasellar cistern and the base of the Sylvian fissure. (B) Six days later, repeat CT showing absorption of the SAH. (C) CTA of the superior-inferior view showing the arterial network of the right proximal MCA (frame) and an aneurysm (arrow). (D) CTA of the posterior-anterior view showing the aneurysm in detail; the aneurysm (arrow) was located in the A1 segment of the ACA. ACA, anterior cerebral artery; A1, first segment of the ACA; A2, second segment of the ACA; BA, basilar artery; CT, computed tomography; CTA, CT angiography; MCA, middle cerebral artery; R, right; SAH, subarachnoid hemorrhage.
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F1
The computed tomography (CT) obtained at the local hospital showed a grade 1 subarachnoid hemorrhage (SAH) on the modified Fisher scale (Figure 1A). CT was repeated and showed that the SAH had been absorbed (Figure 1B). CT angiography showed the arterial network of the right proximal MCA and an aneurysm on the A1 segment of the ACA (Figures 1C, D).
Angioarchitecture of twig-like MCA. (A) Two-dimensional DSA of the right ICA showing a right twig-like MCA and an aneurysm (arrow) at the origin of the AccMCA from the A1 segment. (B) Three-dimensional DSA showing that the ICA (arrowhead) did not give off the branch supplying the twig-like MCA; the arrow indicates the aneurysm. (C) Three-dimensional DSA showing the AccMCA (arrowhead) as a collateral artery from the A1 segment supplying the twig-like MCA; the arrow indicates the aneurysm. (D) Three-dimensional DSA showing that the AchA (arrowhead) supplies the twig-like MCA. A1, first segment; AccMCA, accessory middle cerebral artery; ACA, anterior cerebral artery; AchA, anterior choroidal artery; DSA, digital subtraction angiography; ICA, internal carotid artery; MCA, middle cerebral artery.
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F2
A1 segment of the ACA, and the AccMCA was a collateral artery for the MCA twig (Figure 2). After the three-dimensional reconstruction of the DSA data, the best projection degree showed the aneurysm sac and its neck. An Echemon-10 microcatheter (Medtronic, Irvine, CA, USA) was used to perform the coiling [Axium Prime coils: 3.5 mm x 10 cm, 2 mm x 6 cm, 1.5 mm x 3 cm (Medtronic, Irvine, CA, USA)], and the aneurysm was completely embolized (Figures 3A, B).
Aneurysm coiling and follow-up CT. (A) DSA roadmap navigation of the right ICA showing that the microcatheter was positioned into the aneurysm sac (arrow); the arrowhead indicates the AccMCA. (B) Postoperative DSA of the right ICA showing that the aneurysm was completely coiled and that the AccMCA (arrowhead) was preserved. (C) Follow-up CT showing normal brain tissue. (D) CT reconstruction showing the coils (arrow). A1, first segment; AccMCA, accessory middle cerebral artery; CT, computed tomography; DSA, digital subtraction angiography; ICA, internal carotid artery; MCA, middle cerebral artery; R, right.
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F3
A1 segment of the ACA, and the AccMCA was a collateral artery for the MCA twig (Figure 2). After the three-dimensional reconstruction of the DSA data, the best projection degree showed the aneurysm sac and its neck. An Echemon-10 microcatheter (Medtronic, Irvine, CA, USA) was used to perform the coiling [Axium Prime coils: 3.5 mm x 10 cm, 2 mm x 6 cm, 1.5 mm x 3 cm (Medtronic, Irvine, CA, USA)], and the aneurysm was completely embolized (Figures 3A, B). A postoperative CT at the 3-month follow-up showed that the brain tissue was normal (Figures 3C, D).