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Surgical treatment of anterior communicating artery (Acom) aneurysm is challenging due to anatomic complexity. We aimed to describe our experiences with endovascular treatment (EVT) of Acom aneurysms, and to evaluate the incidence and risk factors of recurrence and retreatment.

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In our study, recurrence rate of Acom aneurysms after EVT was 14.6%. Rupture, anterior dome direction, maximal diameter, and mean age were significantly associated with recurrence. Retreatment rate of recurrent Acom aneurysms after EVT was 3.8%. Patients with Acom aneurysms with large inflow, rupture, large size, or incomplete occlusion may be at a high risk of retreatment of recurring aneurysm.

Anterior communicating artery (Acom) aneurysm has a higher risk of rupture than the other aneurysms [1]. Therefore, treatment of Acom aneurysm is essential and critical for prevention of aneurysmal subarachnoid hemorrhage. However, surgical treatment of Acom aneurysm is still challenging due to anatomic complexity. Acom aneurysm shows a variety of anomalies and complex anatomy like fenestrated, triplicated, and azygous anterior cerebral artery. It also has many perforator and associated vessels such as the recurrent artery of Heubner, anterior lenticulostriate, and bilateral A1 and A2 arteries [2,3,4]. Furthermore, surgical clipping of Acom aneurysm sometimes require a dissection of the rectus gyrus or olfactory nerve.

At the initial coiling, all aneurysms were evaluated with 3D angiogram (Allura Xper FD20/20 and Allura Clarity, Philips Medical Systems, Best, The Netherlands). Based on 3D angiogram findings, aneurysm factors including maximal size, size ratio, inflow angle, hypoplastic A1, and dome direction were evaluated. Size ratio was calculated by dividing the aneurysm maximal size (mm) by the average size of both A1 segments (mm) [8]. Inflow angle was defined as the angle between the maximal height of the aneurysm and the parent vessel [9]. Hypoplastic A1 was defined as A1 with diameter less than 50% of the diameter of contralateral A1 [10]. Additionally, we dichotomized aneurysm direction into anterior or posterior by drawing an imaginary perpendicular line to the anterior cranial fossa using sagittal view of computed tomography (CT) angiography [11]. All radiologic images were retrospectively reviewed by two investigators with consensus. For the correction of different values between the two investigators, mean values were obtained.

This study evaluated the incidence and risk factors of recurrence and retreatment of anterior communicating artery (Acom) aneurysm after endovascular treatment. We found that the recurrence rate of Acom aneurysm after EVT was 14.6%, and its risk factors were younger age, rupture status, aneurysm size, and anterior dome direction. The rate of retreatment was 3.8% and large inflow angle, ruptured status, aneurysm size, and incomplete aneurysm occlusion were risk factors of retreatment.

Anterior communicating artery (AComA) aneurysm rupture is the most common cause of subarachnoid hemorrhage worldwide. In this study, we aimed to determine the factors associated with a poor clinical outcome in patients with ruptured AComA aneurysms undergoing microsurgical clipping.

The anterior communicating artery (AComA) is the most common location for intracranial aneurysms [1,2,3,4]. In recent years, ruptures of AComA aneurysms have been treated using endovascular treatment techniques. Nevertheless, microsurgical clipping remains the mainstay of treatment for aneurysms in this area because ruptures recur at a low rate and few subsequent treatments are needed following clipping [5].

Variations in the structure of the anterior cerebral artery (ACA), such as hypoplasia of the A1 segment, fenestrated AComA, and accessory (triplet) A2 segment, were reviewed. A1 segment hypoplasia was considered present when the A1 width on one side was

This study attempts to analyse the intra-operative anatomical findings of the recurrent artery of Heubner in 48 patients with Anterior Communicating Artery Aneurysm who were operated on at the Neurosurgical Department of Atatürk University Medical School, Erzurum, Türkiye. All patients underwent radical surgery for aneurysm by the right pterional approach. The findings were recorded during surgical intervention and through the dias and videotapes of the operations. The artery of Heubner originated from the junction of the A 1 and A 2 segments of the anterior cerebral artery (ACA) in 58%, from the A 2 segment of ACA in 23%, and from the A 1 segment of ACA 4%. It was asymmetrically taking off in 13% and hypoplastic in 2% of the cases.

Three types of recurrent artery courses were defined. The type I or the superior course was seen in 71 %, the type II or the anterior course was found in 25% and type III or the posterior course was recorded in 4% of patients.

We concluded that the recognition of the anatomical variations of the recurrent artery of Heubner and the detailed knowledge of the microvascular relationships of the anterior communicating artery (ACoA) complex, will allow neurosurgeons to construct a better and safer microdissection plan, to save time, and so prevent postoperative neurological deficit.

Hemicrania continua has been reported in association with a variety of intracranial pathologies especially traumatic brain injury, sinusitis, primary and secondary brain tumours, internal carotid artery dissection, dental, orbital and temporomandibular joint problems [3, 4]. Rarer secondary causes of hemicrania continua include carotid cavernous fistula and cerebral vein thrombosis (CVT) [5, 6]. There is however only one case report of hemicrania continua in relation to an intracranial aneurysm, and this was of the internal carotid artery [7]. Cerebral aneurysms on the other hand have been reported in association with other trigeminal autonomic cephalalgias such as cluster headaches and short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT) [8, 9].

In this study, we report one case of rare pituitary adenoma apoplexy caused by the rupture of an anterior communicating artery aneurysm. The patient was a 49-year-old male who had an untreated pituitary adenoma for 3 years. The patient experienced a sudden headache; computed tomography (CT) and magnetic resonance imaging (MRI) revealed pituitary adenoma apoplexy and significant subarachnoid hemorrhage. Cranial CT angiography (CTA) showed a communicating artery aneurysm. Supratentorial intracranial aneurysm clipping and pituitary adenoma resection were performed. The aneurysm was a ruptured aneurysm located inside the pituitary adenoma. During the surgery, the aneurysm was clipped, and the majority of the tumor was resected. The patient recovered well after the surgery and received radiotherapy.

The coexistence of a cerebral aneurysm and a pituitary adenoma is not uncommon; however, the presence of an aneurysm inside a pituitary adenoma is rare [1]. Among the cases of pituitary adenoma associated with aneurysm, most aneurysms were discovered by accident and were not ruptured. The symptoms in these cases were mainly from the pituitary adenoma [2]; the main manifestations were hormonal disorders and optic nerve compression symptoms. A small number of pituitary adenomas presented as hemorrhagic apoplexy. The main reason for apoplexy is the rupture of nutrient arteries inside the tumor [3, 4]. Among the cases of pituitary adenoma associated with aneurysm, hemorrhagic apoplexy caused by the associated aneurysm is rare. This article reports one case of pituitary adenoma apoplexy caused by rupture of an anterior communicating artery aneurysm and reviews the literature to increase the understanding of this disease.

Craniotomy images. a A tumor in the optic chiasm was observed. The carotid artery, optic nerve, and tumor were clearly displayed. b, c Images of the anterior communicating artery aneurysm (before and after clipping) are displayed. d The surroundings were explored after aneurysmal closure. The aneurysm was observed to be encased by the surrounding tumor

CTA after aneurysm clipping. a, b The image of the aneurysm clip is clearly displayed. The anterior communicating artery aneurysm was completely clipped and closured. There was no residual neck of the aneurysm. The morphology and course of the Willis Circle was normal, without compression and displacement changes

Pituitary adenoma combined with intracranial aneurysm is not rare. The studies of Pant et al. demonstrated that approximately 7.4 % of pituitary adenomas were combined with an aneurysm; 97 % of these aneurysms were located in the anterior circulation [1]. Because both pituitary adenomas and cerebral aneurysms are common intracranial lesions, these two lesions sometimes coincide and occur concurrently; however, to date, no exact incidence of pituitary adenoma associated with intracranial aneurysm has been determined; nonetheless, there is a general consensus that intracranial aneurysms occur more frequently in association with pituitary adenomas than among the general patient population. In addition, associations with intracranial aneurysms are generally thought to be stronger for patients with pituitary adenomas than for patients with other brain tumors, although the manner in which a pituitary adenoma contributes to the formation of an intracranial aneurysm remains unclear [5]. Thus, in addition to speculation of an accidental encounter between a pituitary adenoma and an intracranial aneurysm, there exist other hypotheses to explain the manifestations in the described case.

Among the pituitary adenomas associated with aneurysms, aneurysms at the cavernous sinus segment are the most common. This type of aneurysm is mostly embedded inside the pituitary adenoma below the sellar diaphragm [10]. In cases involving pituitary adenoma combined with an aneurysm, most of the aneurysms are inactive and unruptured. The clinical symptoms are mainly caused by hormones secreted by pituitary adenomas or by compression on the surrounding brain tissues and optic nerve [3]. However, pituitary adenomas have a rare hemorrhagic clinical presentation, namely, tumor apoplexy; thus, the combined aneurysm factor should be considered. A simple pituitary apoplexy is mainly caused by the rupture and hemorrhage of blood-supplying arteries within tumors; the major presentations are a hemorrhage confined within the tumor, a rapid increase in the tumor volume caused by this hemorrhage, and severe headache and vision loss caused by compression of the optic nerve and surrounding dura [4]. When a pituitary adenoma is combined with an aneurysm under the sellar diaphragm, if the aneurysm is ruptured, it may also cause the typical pituitary adenoma apoplexy symptoms. For example, in 2001, Suzuki et al. reported one case of an intracavernous carotid artery aneurysm embedded in a pituitary adenoma. The hemorrhage after rupture was confined inside the tumor, and the presentation included the typical pituitary adenoma apoplexy symptoms and imaging results [11]. 041b061a72


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