Vascular anomaly and aneurysmal formation of an anterior communicating artery (ACOM) complex has often been reported. Because of such a complicated relationship between the vascular structure and aneurysms, ACOM aneurysm is one of the most difficult aneurysms to treat among other common anterior circulation aneurysms. We herein report a case of wire perforation of a missed tiny aneurysm arising from the fenestrated A1 segment during the endovascular approach to ACOM aneurysm. Although the fenestration of A1 segment is a rare vascular anomaly, it is likely to accompany saccular type aneurysms in the vicinity of the vascular anomaly. Endovascular treatment for ACOM aneurysm requires more detailed evaluations of the accompanying vascular anomaly and hemodynamics around ACOM to avoid complications.
Vascular anomaly and aneurysmal formation of an anterior communicating artery (ACOM) complex has often been reported [
An age 77 female was incidentally diagnosed with an unruptured left ACOM aneurysm. She had been diagnosed with early-staged lung cancer two months ago, and a cerebral aneurysm was discovered in the course of determining the disease’s stage. Cerebral angiography revealed a 7 mm ACOM aneurysm with A1 fenestration (
Cases of anomaly in the region of the ACOM are numerous, and many studies have reported on ACOM aplasia, duplication of the ACOM or A1 segment, A1 hypoplasia or aplasia, azygous ACA, a median artery of the corpus callosum, and ACA fenestration [
ACA fenestration has been reported in 0.1-7.2% of dissected autopsy specimens, more frequent than in the distal A1 segment [
Perforation of a parent artery by a guidewire may have a better prognosis than rupture of a dysplastic vessel or aneurysm [
Although fenestration of the A1 segment is a rare vascular anomaly, it is likely to accompany saccular type aneurysms in the vicinity of the vascular anomaly. To avoid endovascular procedure-related complications, detailed preoperative evaluations of the anatomical structure and hemodynamics around the fenestration are critical.
This work was supported by clinical research grant from Pusan National University Hospital in 2021.
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Subtracted (A) and 3D (B) images of left ICA angiography showing a 7 mm ACOM aneurysm with ACOM fenestration (arrows). ICA, internal carotid artery; ACOM, anterior communicating artery
Leak of contrast agent surrounding mid A1 indicates intraprocedural bleeding, suspecting A1 dissection by microwire.
Unsubtracted image (A) acquired immediately after stent-assisted coiling using the waffle-cone technique (B) shows no more leak of contrast agent with complete aneurysm occlusion.
(A) Repeated cerebral angiography immediately after rebleeding reveals contrast leakage (arrows) from the proximal fenestrated A1 segment. (B) Unsubtracted image shows immediately embolized leaking point using coils (arrow).
Another angle of initial angiography shows a missed tiny aneurysm (arrow) arising from the proximal end of the left fenestrated A1 segment.