10 Giant Anterior Communicating Artery Aneurysm Complicated by Visual Deterioration after Coiling

10

Giant Anterior Communicating Artery Aneurysm Complicated by Visual Deterioration after Coiling

SERGEY SPEKTOR AND FELIX UMANSKY

Diagnosis Giant ACoA aneurysm

Problems and Tactics A giant anterior communicating artery (ACoA) aneurysm was found in a 52-year-old woman who was evaluated for rapid visual deterioration. Embolization with Guglielmi detachable coils (GDC) was proposed as the first treatment option. Subtotal obliteration of the aneurysms with coils (19 GDCs) was achieved, but the vision did not improve. Visual function deteriorated to near complete blindness in one eye and severe amblyopia in the other. Craniotomy, with evacuation of the intraaneurysmal clot and coils along with clipping of the aneurysm was performed. This resulted in dramatic and complete recovery of the patient’s vision.

Keywords Anterior communicating artery giant aneurysm, Guglielmi detachable coils, aneurysm clipping, optic nerve

Clinical Presentation

A 52-year-old woman, previously healthy, presented with a gradual onset of headaches of increasing severity. Two weeks later she noticed visual deterioration in her left eye. Magnetic resonance imaging was performed revealing a large, round suprasellar lesion, suspicious for a giant aneurysm. The lesion distorted and compressed the optic nerves. Cerebral angiography was performed revealing a giant aneurysm of the anterior communicating complex. On detailed examination, the aneurysm had a broad neck, originating from the distal part of the A₁ segment of the left anterior cerebral artery (ACA), the entire anterior communicating artery (ACoA), and from the junction of the two arteries (Fig. 10–1).

Endovascular embolization of the aneurysm was performed. All in all, 19 Guglielmi detachable coils (GDCs) were implanted, filling almost the entire aneurysm except for a portion adjacent to the neck and the ACA complex (Fig. 10–2).

After embolization, there was some relief of the headaches. Despite near complete obliteration of the aneurysm, the patient’s vision continued to deteriorate. Two weeks after embolization, she only had light perception in her left eye and finger counting in the right eye. The patient was transferred to our hospital.

Surgical Technique

The patient was operated via a bifrontal craniotomy. The frontal lobes were elevated, the arachnoid dissected, and the olfactory tracts preserved. A giant clotted aneurysm came into view. It distorted and elevated the chiasm, spreading apart both optic nerves, severely compressing them against the A₁ segments of the ACAs. The aneurysm originated from the anterior cerebral artery/anterior communicating artery complex. The A₁ segments and the ACoA were also partially involved in the aneurysmal wall (Fig. 10–3A). The aneurysm’s most proximal part was still patent with turbulent flow visible through the thin wall at high magnification. Meticulous dissection of the arteries was performed. First, the proximal parts of the A₁ segments were separated from the aneurysmal wall. On the right side, the recurrent artery of Heubner was also adherent to the aneurysm, and this was separated and elevated first, enabling access to the right A₁ segment. Dissection of the A₁ in a distal direction was then continued to expose the aneurysmal neck. It was somewhat difficult to perform the dissection on a tense aneurysmal wall. Temporary clips were applied to both A₁ segments and the dome of the aneurysm was incised. A large clot with tightly packed GDCs was removed (Fig. 10–3B). There was almost no retrograde bleeding, which indicated poor collateral flow. To restore the blood flow into the distal part of the ACAs, one of the A₁ segments together with the ACoA was opened as soon as possible. The aneurysmal wall was teased from the right A₁ with gentle dissection in a proximal to distal direction finally releasing the entire segment. In the same fashion, the major part of the ACoA was then released. A large straight clip was applied across the body of the aneurysm as close to the neck as possible. The temporary clip was removed from the right A₁, restoring blood flow into both distal ACAs (the left one was now filling from the right through the ACoA). The duration of temporary clipping was 7 minutes. An attempt to remove the clip from the left A₁