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      An Unruptured Anterior Communicating Artery Aneurysm with Bilateral Infraoptic Anterior Cerebral Arteries. Case Report and Review of the Literature

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          Abstract

          Variations of the anterior cerebral artery-anterior communicating artery complex are commonly identified in aneurysm surgery. An infraoptic course of the anterior cerebral artery is exceedingly rare. Robison first described this anomaly from an anatomic dissection in 1959. A unilateral anomalous infraoptic anterior cerebral artery is more common than anomalies of bilateral infraoptic anterior cerebral arteries. We present the case of an unruptured aneurysm at the anterior communicating artery in a patient with bilateral infraoptic anterior cerebral arteries, identified by computed tomography angiography and verified during surgery. Implications for aneurysm formation and surgical treatment are discussed.

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          Most cited references 15

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          Infraoptic course of the anterior cerebral artery associated with an anterior communicating artery aneurysm: anatomic case report and embryological considerations

          OBJECTIVE AND IMPORTANCE: An infraoptic course of the proximal anterior cerebral artery is a rare anomaly that has been reported in 32 cases to date, often in association with cerebral aneurysms. This anomaly represents a maldevelopment in the embryogenesis of the anterior circle of Willis, resulting from the persistence of the primitive prechiasmal arterial anastomosis or an error in the development of the definitive ophthalmic artery (OphA). The case of a patient with a ruptured middle cerebral artery aneurysm and an anterior communicating artery aneurysm associated with this anomaly is described, and the anatomic features are outlined. CLINICAL PRESENTATION: A 30-year-old male patient with a right temporal hematoma and subarachnoid hemorrhage was admitted to our department 4 days after the hemorrhaging episode, with normal neurological examination results. Angiography revealed a right middle cerebral artery aneurysm and an anterior communicating artery aneurysm with an anomalous precommunicating tract. INTERVENTION: The patient was surgically treated 14 days after the hemorrhaging episode, through a right frontopterional craniotomy; both aneurysms were excluded by clipping. The anomalous infraoptic proximal tract of the anterior cerebral artery was well documented, with its origin adjacent to the OphA. The patient remained neurologically intact after surgery and was discharged 8 days later. CONCLUSION: The anomalous infraoptic course of the proximal anterior cerebral artery was associated with a low bifurcation of the ipsilateral internal carotid artery and the absence of the contralateral precommunicating tract in this patient. The strict anatomic relationship with the origin of the OphA suggests an error in the development of the definitive OphA, with persistence of an anastomotic loop between the primitive dorsal and ventral OphAs. It is concluded that, for aneurysm surgery, careful angiographic evaluation and an understanding of the neurovascular relationships in the circle of Willis are essential for a successful postoperative course, especially when very rare vascular anomalies are treated.
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            Infraoptic anterior cerebral artery: review, report of two cases and an anatomical classification.

            Infraoptic course of the pre-communicating anterior cerebral artery (A1) is a rare anomaly. In total, there are 42 examples reported in the literature. We report two further patients. The first had an intradural cerebral aneurysm at the low bifurcation of an internal carotid artery (ICA) with bilateral infraoptic course of A1. The second had right infraoptic course of A1 with associated left parietal cerebral arteriovenous malformation and is the first report of such an association. Overall, 59% of the examples were associated with cerebral aneurysms. Different terminology such as carotid-anterior cerebral artery anastomosis and infraoptic anterior cerebral artery has been used. Having analyzed the reports of infraoptic A1, we found the vascular configurations of the A1 could be better described by classifying them into four types. Such a classification can facilitate analysis of the embryogenesis explanation for this anomaly and the pathogenesis of the associated aneurysms. Besides, such a classification also has some practical implications.
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              An unusual human anterior cerebral artery.

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                Author and article information

                Journal
                J Cerebrovasc Endovasc Neurosurg
                J Cerebrovasc Endovasc Neurosurg
                JCEN
                Journal of Cerebrovascular and Endovascular Neurosurgery
                Korean Society of Cerebrovascular Surgeons; Society of Korean Endovascular Neurosurgeons
                2234-8565
                2287-3139
                December 2014
                30 December 2014
                : 16
                : 4
                : 368-373
                Affiliations
                [1 ]Harvard Medical School, Boston, MA, United States.
                [2 ]Department of Neurosurgery, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA, United States.
                Author notes
                Correspondence to Christopher S. Ogilvy. Department of Neurosurgery, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite 3B Boston, MA 02215, USA. Tel: 1-617-632-7246, Fax: 1-617-632-0949, cogilvy@ 123456bidmc.harvard.edu
                Article
                10.7461/jcen.2014.16.4.368
                4296050
                © 2014 Journal of Cerebrovascular and Endovascular Neurosurgery

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Case Report

                Surgery

                vascular surgical procedure, aneurysm, anterior cerebral artery

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