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 ::  Abstract
 ::  Introduction
 ::  Case Report
 ::  Discussion
 ::  Conclusion
 ::  References
 ::  Article Figures
 ::  Article Tables

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  Table of Contents     
CASE REPORT
Year : 2011  |  Volume : 57  |  Issue : 1  |  Page : 44-47

Kissing anterior communicating artery aneurysms: Diagnostic dilemma and management issues


Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences, & Technology, Trivandrum, India

Date of Submission01-May-2010
Date of Decision21-Jun-2010
Date of Acceptance20-Sep-2010
Date of Web Publication31-Jan-2011

Correspondence Address:
G Menon
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences, & Technology, Trivandrum
India
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DOI: 10.4103/0022-3859.74288

PMID: 21206124

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 :: Abstract 

Kissing aneurysms are unusual and relatively rare types of multiple intracranial arterial aneurysms. When located on the anterior communicating artery (ACoA), kissing aneurysms pose considerable diagnostic difficulty on preoperative conventional angiogram. Special angiographic views or 3D rotational angiogram are needed to make the correct diagnosis and to avoid interpreting them as multilobed or bilobed saccular aneurysms on preoperative conventional angiogram. Treatment of these aneurysms, either by clipping or coiling, needs to be individualized. Unique problems which need to be addressed during surgical clipping are high risk of rupture due to dense adhesions between the kissing aneurysms, requirement of at least two clips in a narrow working area, the aneurysm that needs to be clipped first and interference of the first clip with application of subsequent clips. The authors present a case of a 63-year-old male who had kissing ACoA aneurysms managed successfully by clipping.


Keywords: Anterior communicating artery, kissing aneurysms, mirror aneurysms, multiple aneurysms


How to cite this article:
Baldawa S S, Menon G, Nair S. Kissing anterior communicating artery aneurysms: Diagnostic dilemma and management issues. J Postgrad Med 2011;57:44-7

How to cite this URL:
Baldawa S S, Menon G, Nair S. Kissing anterior communicating artery aneurysms: Diagnostic dilemma and management issues. J Postgrad Med [serial online] 2011 [cited 2014 Jul 29];57:44-7. Available from: http://www.jpgmonline.com/text.asp?2011/57/1/44/74288



 :: Introduction Top


The occurrence of multiple intracranial aneurysms has been well described in literature. Multiple aneurysms account for 20% of all intracranial aneurysms. [1],[2] However, the finding of more than one aneurysm on the same artery is rare, the incidence being 2.8%. [3] Multiple aneurysms on the same artery are reported usually in the internal carotid artery [2],[3],[4] or the middle cerebral artery; [5],[6] such a finding with anterior communicating artery (ACoA) is quite rare. Kissing aneurysms are variants of multiple aneurysms. We report a case of 63-year-old gentleman who presented with aneurysmal subarachnoid hemorrhage and underwent successful surgical clipping of kissing ACoA aneurysms.


 :: Case Report Top


A 63-year-old hypertensive gentleman was admitted to the neurosurgical department with history of sudden onset severe holocranial headache and vomiting of 2 days duration. On admission, he was fully conscious, alert and had no neurological deficits. Computed tomography (CT) brain revealed subarachnoid hemorrhage in the interhemispheric fissure and bilateral sylvian cisterns [Figure 1] a, b. On 3D CT angiogram (CTA), bilobed saccular aneurysm was seen arising from the ACoA [Figure 1] c, d. However, the possibility of kissing aneurysm could not be ruled out. Four vessel cerebral digital subtraction angiogram (DSA) was performed for better delineation [Figure 2]. It revealed the presence of two aneurysms arising from the ACoA, both projecting superiorly and one of them projecting to right. The right A1 segment was hypoplastic and the ACoA and both A2 segments were filling from a dominant left A1. Left pterional craniotomy was performed and both the ACoA aneurysms were clipped through a transsylvian-subfrontal approach. The bled aneurysm was located more proximally closer to the left A1-A2 junction, projecting superiorly into the interhemispheric fissure and was clipped using a small straight clip. Delineation of the aneurysm required resection of the ipsilateral gyrus rectus. The second aneurysm was arising from ACoA proper and was projecting superiorly and to the right. The "rupture point" was near the dome of the first aneurysm and the "kissing point" was near the fundus of both aneurysms. After clipping and opening the ruptured proximal aneurysmal sac, the second unruptured aneurysm could be well delineated. However, clip application was difficult due to space constraints and it was eventually clipped using a curved small clip. No temporary clip was applied on the left A1 segment. Postoperatively, the patient had uneventful recovery. Angiogram performed on postoperative day 5 revealed good patency of the ACoA segment with no residual aneurysmal neck [Figure 3].
Figure 1: (a, b) Plain CT brain: Subarachnoid blood predominantly in the interhemispheric fissure and bilateral sylvian cistern. (c) Superior view of 3D CTA: Bilobed aneurysm arising from ACoA projecting superiorly and to the right. (d) High resolution image of C-dominant left A1 segment with hypoplastic right A1 segment

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Figure 2: Preoperative conventional angiogram. (a, b) Left ICA injection oblique view: Two kissing aneurysms arising from ACoA - one projecting superiorly and the other projecting superior and to the right. (c) Left ICA injection AP view. (d) Right A1 segment is hypoplastic with non visualization of the aneurysm

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Figure 3: Postoperative angiogram. Left ICA injection (a), lateral view (b), AP view - Two surgical clips seen with no residual aneurysmal neck

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 :: Discussion Top


ACoA region is the most common site for intracranial aneurysms, constituting 30.3% of all intracranial aneurysms. [1] The treatment of ACoA aneurysms is surgically challenging because of their bilateral anterograde arterial supply, their deep midline location and their intimate relationship to 11 crucial arteries and their perforators - paired A1 segments, paired A2 segments, two recurrent arteries of Heubner, two orbitofrontal arteries, two frontopolar arteries and the ACoA. The term ''kissing aneurysms'' refers to two anatomically adjacent aneurysms with different origins and partially adherent walls. [7],[8] In the Circle of Willis, these aneurysms are quite rare and Yasargil reported an incidence of 0.2% (two patients) in his series of 1012 aneurysms. [9] The occurrence of kissing ACoA aneurysms is rare and an extensive PubMed search revealed only a few cases of multiple ACoA aneurysms. [7],[8],[10], [11,[12],[13],[14],[15] [Table 1] provides the details of all these cases. Yasargil has reported some cases of multiple ACoA aneurysms in his classic book, but the clinical details of these patients have not been mentioned. [9]
Table 1: Cases of multiple intracranial ACoA aneurysms reported in literature

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The pathogenesis of multiple ACoA aneurysms is multifactorial. Hemodynamic stress may contribute in the pathogenesis if the proximal ACAs are unequal. In these cases, an aneurysm arises at the corner between the ACoA and the A2 segment located ipsilateral to the dominant A1 segment. [11] The role of systemic arterial hypertension has also been emphasized. [16] Multiple ACoA aneurysms are associated with vasculitis, polycystic kidney disease, EhlersDanlos syndrome, Wegener's granulomatosis and other connective tissue disorders.

Harada et al. have classified kissing aneurysms into two groups based on the location of the aneurysmal neck. [5] In Type 1 kissing aneurysms, each aneurysmal neck is located on the same parent artery. In Type 2, each aneurysmal neck arises from different parent arteries. Kissing ACoA aneurysms belong to Type 1 kissing aneurysms. [5]

The preoperative diagnosis of multiple or kissing or mirror ACoA aneurysms by conventional angiogram is often difficult. Multiple ACoA aneurysms are frequently misinterpreted as aneurysmal bleb, single multilobed or bilobed saccular aneurysm. [11],[12] The differentiation between single multilobed and multiple saccular aneurysms is of immense significance for surgical planning and to avoid intraoperative complications. Additional angiographic projections such as the transorbital-oblique, Caldwell oblique, oblique-submentovertex projections should be obtained in the presence of bilobed or multilobed saccular aneurysm. [11] 3D CTA or 3D rotational angiography enables differentiation between the two. [17],[18] Nevertheless, this differentiation may not be always possible preoperatively and often kissing aneurysms are an intraoperative surprise. [10],[11] Harada et al. reviewed 23 cases in the literature and found that 13 (57%) of them had not been recognized as kissing aneurysms preoperatively. [5] In Servet et al.'s series, special angiographic projections enabled identification of multiple ACoA aneurysms in five out of six patients. In one patient, the occurrence of two ACoA aneurysms was a surprise finding during surgery. [11] In our patient, although the 3D CTA was suspicious, the kissing aneurysms were identified on conventional DSA. The other major concern is angiographic identification of the ruptured aneurysm among the two kissing aneurysms. The standard criteria such as proximal location, larger size, daughter blebs, local vasospasm, and site of the haematoma do not often aid in detecting the bled aneurysm as was the case with our patient. In Servet et al.'s series, the ruptured ACoA aneurysm could be identified in only three out of six patients. [11]

Though conventional angiogram is the gold standard for the diagnosis of intracranial aneurysm, 3D rotational angiography provides detailed information of vascular anomalies commonly associated with ACoA aneurysms which makes surgical or endovascular treatment challenging. ACoA complex is a frequent site of unilateral anterior cerebral artery (ACA) hypoplasia, arterial duplications, fenestrations, dimple, fusion, median artery of corpus callosum and azygous ACA. [18]

Surgical clipping of kissing ACoA aneurysms is associated with multiple challenges. In the presence of multiple aneurysms, which one of these aneurysms needs to be clipped first is controversial. [11] The general rule is to clip the bled aneurysm first, but it is often difficult to identify the bled aneurysm intraoperatively as the "rupture point" and the "kissing point" are surrounded by dense clots and adhesions. The presence of the first clip may obstruct access to the second aneurysm. Clipping the farthest unruptured aneurysm first may be an alternative but clipping of this unruptured aneurysm can result in traction on the other ruptured aneurysm causing premature secondary rupture. Kinking of the vessel after the first clip application may occur. Care should be taken to apply the clips as parallel to the parent vessel as possible. The narrow working space around each aneurysm neck compounds the above problems during clip application. [7],[8],[11],[12]

Certain general principles help in the successful clipping of kissing ACoA aneurysms. Resection of the gyrus rectus as done in this case enables better exposure of the aneurysm complex. [11] Application of temporary clip on the A1 segments, though was not necessary in our case, enables dissection and clipping of the aneurysm and prevents intraoperative rupture. [12] The necks of the both the aneurysms should be prepared properly before the first clip is placed. In our case, after dissection of the neck of both the aneurysms, we clipped the proximal ruptured aneurysm first. Coagulation and excision of this ruptured aneurysmal sac enabled better visualization of the second unruptured aneurysm. We agree with Servet et al. in the use of straight clips with short blades because angled clips restrict the surgeon's view in the narrow operative space. [11] The sequence of clipping must however be appropriately modified to the particular anatomy of the individual patient.

Considering the surgical challenges involved, endovascular coiling of kissing aneurysms is another treatment option available, especially if the two aneurysms have narrow neck, favorable configuration and the patient is in poor grade and at high risk for general anesthesia. [8],[19] Coiling reduces the risk of open surgery, brain injury which occurs during surgical retraction, minimizes the risk of premature rupture as coil sequencing is a not a major concern and dissection around the aneurysm neck is not needed. [7] Space constraint is not a hindrance during coiling. However, endovascular treatment has its limitations. Rupture of the aneurysm can result in torrential bleeding and eventual mortality. [7],[8] Coiling of broad neck aneurysms is not recommended. Hence, the ultimate management strategy depends on the expertise of the vascular surgeon, endovascular facilities available and aneurysm characteristics.


 :: Conclusion Top


Although kissing ACoA aneurysms are exceedingly rare, all cereberovascular surgeons need to be aware of this entity. Presence of bilobed or multilobed ACoA aneurysms should raise the suspicion of kissing aneurysms. Appropriate advanced imaging like special angiographic views, 3D CTA or 3D rotational angiogram should be performed for better delineation. With careful preoperative planning and meticulous surgical techniques like gyrus rectus resection, applying temporary clips on A1 segment, coagulation and shrinkage of one aneurysmal sac, appropriate clip selection and sequencing, kissing ACoA aneurysms can be successfully clipped.

 
 :: References Top

1.Locksley HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg 1966;25:219-39.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Jefferson A. The significance for diagnosis and for surgical technique of multiple aneurysms of the same internal carotid artery. Acta Neurochir 1978;41:23-37.  Back to cited text no. 2
    
3.Kojima T, Waga S. More than one aneurysm on the same artery. Surg Neurol 1984;22:403-8.   Back to cited text no. 3
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4.Sato O, Kanazawa I, Kokunai T, Kobayashi M. Seven intracranial aneurysms of the internal carotid artery. Diagnosis by magnification angioautotomography. Neuroradiology 1978;15:189-92.   Back to cited text no. 4
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5.Harada K, Orita T, Ueda Y. Large kissing aneurysms of the middlecerebral artery: a case report- classification of kissing aneurysms. No Shinkei Geka 2004;32:513-7.  Back to cited text no. 5
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6.Cedzich C, Schramm J, Rockelein G. Multiple middle cerebral artery aneurysms in an infant. Case report. J Neurosurg 1990;72:806-909.   Back to cited text no. 6
    
7.Hiroaki M, Akihiko Ti, Kanehisa K, Ushio S. Kissing aneurysms of the anterior communicating artery treated with coil embolization. J Endovasc Ther 2005;12:750-4.   Back to cited text no. 7
    
8.Sang JS, Dong GK, Kee YR, Jae HC. Endovascular treatment of kissing aneurysms at the anterior communicating artery. J Korean Neurosurg Soc 2008;44:163-5.   Back to cited text no. 8
    
9.Yasargil MG. Microneurosurgery. New York: Thieme; 1984. p. 165-231.  Back to cited text no. 9
    
10.Jae MK, Nok YL, Jin HC, Koang HB, Choong HK, Suck JO. Multiple aneurysms in the anterior communicating artery. J Korean Neurosurg Soc 2002;31:170-2.   Back to cited text no. 10
    
11.Servet I, Tunclap O. Multiple aneurysms of the anterior communicating artery: Radiological and surgical difficulties. J Neurosurg 2005;102: 495-502.  Back to cited text no. 11
    
12.Wanifuchi H, Shimizu T, Higa T, Nakaya K. Kissing mirror image anterior communicating artery aneurysms. Neurol Med Chir 2001;41:29-32.   Back to cited text no. 12
    
13.Walsh FB, King AB. Ocular signs of intracranial saccular aneurysms. Experimental work on collateral circulation through the ophthalmic artery. Arch Ophthal 1942;27:1-33.  Back to cited text no. 13
    
14.Bigelow NH. Multiple intracranial arterial aneurysms: an analysis of their significance. AMA Arch Neurol Psychiatry 1955;73:76-99.  Back to cited text no. 14
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15.Koeller KK, Osborn RE. Multiple aneurysms of the anterior communicating artery. Am J Osteopath Assoc 1991;91:899-900.   Back to cited text no. 15
    
16.Erbengi A, Inci S. Pheochromocytoma and multiple intracranial aneurysms: is it a coincidence? Case report. J Neurosurg 1997;87:764-7.   Back to cited text no. 16
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17.Beck J, Rohde S, Berkefeld J, Seifert V, Raabe A. Size and location of ruptured and unruptured intracranial aneurysms measured by 3-dimensional rotational angiography. Surg Neurol 2006;65:18-25.   Back to cited text no. 17
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18.De Oliveira JG, De Rochemont RD, Beck J, Hermann E, Gerlach R, Raabe A, et al. A rare anomaly of the anterior communicating artery complex hidden by a large broad-neck aneurysm and disclosed by three-dimensional rotational angiography. Acta Neurochir 2008;150:279-84.  Back to cited text no. 18
    
19.Elias T, Ogungbo B, Connolly D, Gregson B, Mendelow AD, Gholkar A. Endovascular treatment of anterior communicating artery aneurysms: results of clinical and radiological outcome in Newcastle. Br J of Neurosurg 2003;17:278-86.  Back to cited text no. 19
    


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