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      Endovascular treatment of a ruptured blister-like aneurysm at an azygos anterior cerebral artery: A case report and review of the literature

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          Abstract

          Background:

          Endovascular treatment for a ruptured blister-like aneurysm (BLA) has recently become a hopeful approach. BLAs are usually located on the dorsal wall of the internal carotid artery, whereas one located on the azygos anterior cerebral artery (ACA) is so rare, it has never been reported. We report a case of a ruptured BLA arising at the distal bifurcation of an azygos ACA treated by stent-assisted coil embolization.

          Case Description:

          A 73-year-old woman presented with a disturbance of consciousness. Computed tomography showed diffuse subarachnoid hemorrhage, which was observed to be particularly dense in the interhemispheric fissure. Three-dimensional rotation angiography showed a tiny and conical bulge on the distal bifurcation of the azygos trunk. Follow-up digital subtraction angiography performed on day 4 showed enlargement of the aneurysm, and a BLA arising at the azygos bifurcation was diagnosed. Stent-assisted coiling (SAC) was performed using a low-profile visualized intraluminal support (LVIS) Jr. stent, which was implanted from the left pericallosal artery to the azygos trunk. Follow-up angiography showed that the aneurysm thrombosed gradually and reached complete occlusion 90 days after onset.

          Conclusion:

          SAC for a BLA at the distal bifurcation of an azygos ACA might be an effective treatment option leading to early complete occlusion, but thrombus formation as an intraoperative complication should be noted in the BLA at the bifurcation or the peripheral artery, as in the present case.

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          Most cited references20

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          Flow diverters at and beyond the level of the circle of willis for the treatment of intracranial aneurysms.

          Flow Diverters (FD) are a new emerging therapy for intracranial aneurysms. Initial reports focused on the treatment of proximally located aneurysms. We report our experience with FDs in the treatment of aneurysms at and beyond the circle of Willis. We treated 30 aneurysms at and beyond the circle of Willis with FDs (silk and pipeline). Aneurysms were treated with FDs alone in 73.3% (22/30) and with FDs and coils in 23.3% (7/30). One procedure was converted in parent vessel occlusion. Thirty aneurysms (21/30, 70.0% saccular; 7/30, 23.3% fusiform; 2/30, 6.7% blister-like; sizes 1.2-19.6, mean 6.8 mm) were treated in 26 patients (17 women, 9 men; mean age, 49 years) during 27 procedures. Access site complication was noted in 3.7% (1/27). Reversible neurological complications were noted in 7.4% (2/27), permanent neurological complication in 3.7% (1/27). There was no mortality. No aneurysms bled or rebled after treatment. Aneurysms treated with FDs alone were significantly smaller than those treated with FDs and coils (5.7 and 10.0 mm, respectively; P=0.0174). Immediate angiographic occlusion was achieved in 18.2% (4/22) with FDs alone, in 0.0% (0/7) with FDs and coils. Twenty-four aneurysms (80.0%) had been followed (mean, 13 months). Fifteen of 19 aneurysms (78.9%) treated with FDs against 4 of 4 of aneurysms (100%) treated with FDs and coils were occluded. There was no angiographic recurrence of initially totally occluded aneurysms. Aneurysms at and beyond the circle of Willis are amenable to selective treatment with FDs.
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            Aneurysms protruding from the dorsal wall of the internal carotid artery.

            Saccular aneurysms arising at locations other than at arterial divisions are extremely rare. The authors describe eight such aneurysms that protruded from the dorsal wall of the internal carotid artery (ICA) and were unrelated to any arterial junction. Radical surgery was performed in all eight cases. The aneurysms were saccular with a fragile wide or semifusiform neck. Intraoperative rupture occurred in three cases. From this experience, it is emphasized that these unusual protruding aneurysms of the dorsal ICA should be clipped with the clip blade parallel to the parent artery. In addition to clipping, complete wrapping with fascia or Bemsheet (cellulose fabric) is often advisable to prevent slippage of clips or postoperative rupture of residual aneurysm.
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              STUDIES ON THE ARTERIES OF THE BRAIN. II. THE ANTERIOR CEREBRAL ARTERY: SOME ANATOMIC FEATURES AND THEIR CLINICAL IMPLICATIONS.

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                Author and article information

                Contributors
                Journal
                Surg Neurol Int
                Surg Neurol Int
                Surgical Neurology International
                Scientific Scholar (USA )
                2229-5097
                2152-7806
                2023
                27 January 2023
                : 14
                : 27
                Affiliations
                [1 ]Department of Neurosurgery, Ehime Prefectural Niihama Hospital, Niihama City, Ehime, Japan,
                [2 ]Department of Neurosurgery, Ehime University Graduate School of Medicine, Toon City, Ehime, Japan
                Author notes
                [* ] Corresponding author: Shirabe Matsumoto, Department of Neurosurgery, Ehime Prefectural Niihama Hospital, Niihama City, Japan. shirabem13@ 123456gmail.com
                Article
                10.25259/SNI_743_2022
                10.25259/SNI_743_2022
                9990775
                36895244
                2decae1b-4106-43b4-a1f0-0c221ffd0138
                Copyright: © 2023 Surgical Neurology International

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                History
                : 16 August 2022
                : 23 December 2022
                Categories
                Case Report

                Surgery
                blister-like aneurysm,azygos anterior cerebral artery,endovascular treatment
                Surgery
                blister-like aneurysm, azygos anterior cerebral artery, endovascular treatment

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