J Cerebrovasc Endovasc Neurosurg.  2016 Jun;18(2):141-146. 10.7461/jcen.2016.18.2.141.

Treatment of a Giant Serpentine Aneurysm in the Anterior Cerebral Artery

• Kim ST
• Jeong YG
• Jeong HW

• KMID: 2354891
• DOI: http://doi.org/10.7461/jcen.2016.18.2.141

Abstract

A giant serpentine aneurysm (GSA) in the anterior cerebral artery (ACA) poses a technical challenge in treatment given its large size, unique neck, and dependent distal vessels. Here we report the case of a GSA in the ACA successfully treated with a combined surgical and endovascular approach. A 54-year-old woman presented with dull headache. On brain computed tomography (CT), a large mass (7 cm × 5 cm × 5 cm) was identified in the left frontal lobe. Cerebral angiography revealed a GSA in the left ACA. Bypass surgery of the distal ACA was performed, followed byocclusion of the entry channel via an endovascular approach. Follow-up CT performed 5 days after treatment revealed disappearance of the vascular channel and peripheral rim enhancement. Follow-up imaging studies performed 7 months after treatment revealed gradual reduction of the mass effect and patency of bypass flow. No complications were noted over a period of 1 year after surgery.

Keyword

Intracranial aneurysm; Anterior cerebral artery; Cerebral revascularization

MeSH Terms

Aneurysm*
Anterior Cerebral Artery*
Brain
Cerebral Angiography
Cerebral Revascularization
Female
Follow-Up Studies
Frontal Lobe
Headache
Humans
Intracranial Aneurysm
Middle Aged
Neck

Figure

• 

  Fig. 1 (A, B) Initial brain computed tomography images showing a heterogeneous large mass (7 cm × 5 cm × 5 cm) with central and rim enhancements (A: non-enhanced axial image; B: enhanced axial image). (C) Five days after treatment. Follow-up brain computed tomography axial view showing disappearance of the vascular channel and peripheral rim enhancement. (D) Four months after treatment.Axial view showing reduction of the mass effect. (E) Seven months after treatment. Axial view showing further reduction of the mass effect.

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  Fig. 2 Internal carotid artery angiography images. (A) Anteroposterior view in the arterial phase showing a giant serpentine aneurysm (GSA) and filling defect of the left distal anterior cerebral artery (ACA) territory (black asterisk: left distal ACA filling defect; white asterisk: GSA lumen with contrast filling). (B) Lateral view in the arterial phase showing a GSA and entry channel (white arrow: entry point of the GSA). (C) Lateral view in the late venous phase showing delayed filling of the left distal ACA territory (small black arrows: territory of the left distal ACA). (D) Oblique view in the late venous phase showing the exit channel of the GSA (black arrow: exit channel of the GSA).

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  Fig. 3 (A) The condition after bypass and before temporary clip removal. (B) Schematic drawing of the treatment plan for the giant serpentine aneurysm (GSA) in the distal anterior cerebral artery (ACA). α: In situ "side-to-side" bypass of both distal ACAs, β: Occlusion of the entry channel via an endovascular approach using detachable coils. Occlusion is performed in 2 steps. First, the distal widest part of the GSA is loosely packed using large coils (green helix). Second, the proximal narrow part between the distal perforator of the feeding artery and the beginning of the aneurysm is densely packed using coils (blue helix).

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  Fig. 4 (A) Lateral view of the working angle after endovascular occlusion showing that the perforating artery is not sacrificed (asterisk indicates the perforating artery). (B) Native view of the working angle showing a loosely packed distal part and densely packed proximal part of thegiant serpentine aneurysm (GSA). (C) Left internal carotid artery angiography in the late arterial phase (anteroposterior view) after entry channel occlusion showing a GSA and patient collateral flow via bypass. (D) Left internal carotid artery angiographyin the capillary phase (lateral view) after entry channel occlusion showing retrograde contrast filling of the GSA (the white arrow indicates retrograde contrast filling).

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