Anterior Cerebral Artery Aneurysm: Incidental Saccular Aneurysms of an Azygos Anterior Cerebral Artery and of the Right-Hand Fenestrated A1 Segment; Endovascular Treatment of both Aneurysms with Stent- and pCONUS1 Assisted Coil Occlusion with Complete Occlusion During Long-Term Follow-Up and with a Good Clinical Outcome
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A 61-year-old male patient with a history of arterial hypertension and chronic nicotine dependence was diagnosed with an incidental distal aneurysm of the anterior cerebral artery (ACA). A magnetic resonance imaging and magnetic resonance angiography (MRI/MRA) examination revealed a wide-necked lobulated saccular aneurysm of the right-hand proximal ACA in the fenestrated A1 segment (maximum diameter 6.5 mm) and another wide-necked lobulated saccular aneurysm of an azygos ACA at the bifurcation site (maximum diameter 8.5 mm). The patient was referred to our neuroradiological service for either microsurgical or endovascular treatment. Both aneurysms carried a potential risk of rupture and subarachnoid hemorrhage (SAH). The decision was taken to occlude the aneurysms. Both aneurysms were treated using an endovascular approach. The proximal ACA/A1 aneurysm was occluded by stent-assisted coiling, and the azygos bifurcation aneurysm was treated by coiling using the so-called waffle-cone technique. Whereas the A1 aneurysm remained excluded from the cerebral blood circulation after the endovascular treatment, the azygos aneurysm showed progressive reperfusion of its sac 3 years later. For the second treatment, a pCONUS1 – a bifurcation stent device – was chosen to support coiling. This device enables safe aneurysm coil occlusion of wide-necked bifurcation aneurysms with a reduced risk of coil herniation into the parent vessel by covering the neck inside the aneurysm. After this second endovascular procedure, the azygos ACA aneurysm remained occluded. This was confirmed 7 years later by DSA, with the patients’ condition being mRS 0. The azygos ACA variant, its frequently associated aneurysms, and the endovascular treatment of azygos ACA aneurysms are the main topics of this chapter.
KeywordsAzygos anterior cerebral artery Proximal anterior cerebral artery, A1 segment Fenestrated A1 segment Stent-assisted oil occlusion Waffle-cone technique pCONUS-assisted coil occlusion
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