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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1067-1069

Bizarre Growth of Partially Thrombosed Giant Aneurysm of Distal Anterior Cerebral Artery—The End of the Treatment is not the End


Department of Neurosciences, Medanta, The Medicity. Gurgaon, Haryana, India

Date of Submission27-Jun-2018
Date of Decision17-Mar-2020
Date of Acceptance15-May-2021
Date of Web Publication2-Sep-2021

Correspondence Address:
Gaurav Goel
Associate Director and Head-Neurointervention Surgery, Department of Neurosciences, Medanta, The Medicity, Gurgaon - 122 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.325354

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How to cite this article:
Mahajan A, Goel G, Das B, Banga V, Narang KS. Bizarre Growth of Partially Thrombosed Giant Aneurysm of Distal Anterior Cerebral Artery—The End of the Treatment is not the End. Neurol India 2021;69:1067-9

How to cite this URL:
Mahajan A, Goel G, Das B, Banga V, Narang KS. Bizarre Growth of Partially Thrombosed Giant Aneurysm of Distal Anterior Cerebral Artery—The End of the Treatment is not the End. Neurol India [serial online] 2021 [cited 2021 Dec 5];69:1067-9. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1067/325354




Sir,

Distal anterior cerebral artery (DACA) aneurysm is located at the bifurcation formed by the origin of the pericallosal artery and callosomarginal artery. They comprise of 1.5–9% of all intracranial aneurysm.[1],[2] Giant aneurysm of DACA aneurysm are extremely rare and is reported by few authors.[1],[3] The natural history of partially thrombosed aneurysm is different from other intracranial aneurysms. Giant partially thrombosed aneurysm (PTA) typically presents with progressive mass effect rather than with subarachnoid haemorrhage. On magnetic resonance imaging (MRI), PTA has smaller patent lumen with surrounding thrombus of different ages in an onion-skin type fashion.[4]

A 64-year-old male presented with a history of three episodes of transient loss of consciousness with complete recovery for 4 days. He was the known case of hypertension, type 2 diabetes mellitus, and coronary artery disease for which he had undergone coronary artery bypass surgery. MRI of brain was done that showed right basifrontal lesion with signal void on T2-weighted image in relation to right internal carotid artery bifurcation and adjacent cingulate gyrus suggestive of aneurysm [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. We advised the patient to undergo digital subtraction angiography of brain; however, he refused for the angiography and decided to continue with medical management. After 1 year and 10 months, he presented with three episodes of focal seizures. He was taking dual antiepileptic medication, which was then escalated. Patient also complained of difficulty in walking and urinary incontinence for 15 days. MRI brain was done, which showed significant interval increase in the size of lesion in the right frontal region with surrounding interval increase in perilesional edema as compared to previous MRI brain [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h. The size of giant ACA aneurysm was 5.1 × 4.6 × 3.9 cm (height × width × length). Mild mass effect and transfalcine herniation toward left side were noted. Patient had agreed this time to undergo cerebral vessels angiography, which showed large aneurysm of distal azygous ACA measuring 17 × 7.8 mm with neck measuring 4.3 mm. Two aneurysms were also noted in right internal carotid artery (ICA) bifurcation and right para ophthalmic ICA. Successful simple endovascular coiling of right DACA and ICA bifurcation aneurysm and balloon-assisted coiling of right para ophthalmic ICA aneurysm were done [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f. Patient underwent noncontrast computed tomography 24 h post procedure, which showed coil mass artifacts and contrast retention along the wall of aneurysm with surrounding vasogenic edema [Figure 2]g and [Figure 2]h. Steroid was given in view of underlying perilesional edema. Antipsychotic medication was also started, and he was discharged from the hospital with an advised to undergo check cerebral angiography after 6 months.
Figure 1: Axial T2-weighted MRI showed heterogeneous signal intensity (SI) lesion in relation to right ICA bifurcation region (arrow in a) and right cingulate gyrus suggestive of aneurysm (arrow). Mild surrounding perilesional edema (b and c). SWI showed blooming in the right cingulate gyrus (d). Follow up MRI after 1 year 10 months showed significant interval increase in size of DACA aneurysm with significant interval increase in perilesional edema (e–g). SWI showed interval increase in the heterogeneous SI of the aneurysm suggestive of partial thrombosis (h)

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Figure 2: Right ICA injection showed right distal ACA partially thrombosed aneurysm (red arrow) (a). Successful coiling was done. Right ICA bifurcation aneurysm (b and c). Successful coiling of right ICA bifurcation (d). Another small aneurysm noted in right para ophthalmic ICA region (red arrow), which was successfully occluded by balloon-assisted coiling (e and f). NCCT head showed coil mass in situ with in the partially thrombosed aneurysm and surrounding perilesional edema (arrow) (g and h)

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After 2 months of the endovascular treatment, patient had two episodes of generalized tonic clonic seizures, and he also complained of multiple episodes of transient loss of consciousness. Patient also presented with confusion and emotional liability. MRI brain was done, which showed thrombosed aneurysm showing no interval change in surrounding edema as compared to previous MRI; however, there was cystic growth of the aneurysm posteriorly and superiorly [Figure 3]a and [Figure 3]b. Susceptibility weighted imaging (SWI) showed blooming within the wall of cystic part of the aneurysm suggestive of haemorrhage in the wall of the aneurysm [Figure 3]c. Right ICA injection showed no recanalization in right internal carotid artery bifurcation aneurysm and para ophthalmic ICA aneurysm; however, there was recanalization of previously coiled DACA aneurysm [Figure 3]d and [Figure 3]e. Thus, there was growth in lumen of the aneurysm likely due to coil compaction and also in the wall of the aneurysm in our case. Repeat coiling was done in view of his worsening of the complaints and growth of the aneurysm evident on imaging [Figure 3]f. Patient symptoms did not resolve even after the repeated coiling but rather worsened despite the best medical and endovascular management. Steroid was restarted along with antiepileptic and antipsychotic medication. Patient was advised clinical follow up and MRI after 3 months; however, he did not appear for the scheduled appointment and he lost to follow up.
Figure 3: Partially thrombosed aneurysm showed no interval change in surrounding edema. Cystic growth (arrow) of the aneurysm posteriorly and superiorly (a and b). SWI showed blooming within the wall of cystic part of the aneurysm (c). No recanalization of right ICA bifurcation aneurysm and para ophthalmic ICA aneurysm (d). Recanalization (arrow) of DACA aneurysm (e). Successful coiling of recanalized DACA aneurysm (f)

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Due to recurrent hemorrhages in the wall of the partially thrombosed giant aneurysm, there may be continued growth of aneurysm. The thrombosed aneurysm wall has rich network of vasavasorum, which is considered to be the origin of haemorrhage.[5] Partially thrombosed large and giant aneurysm may develop vasogenic edema around them and may also develop after coiling. The underlying cause may be due to local inflammatory process and regional blood flow disturbances.[6],[7] In our case, the aneurysm was large at first imaging and showed increased growth over the period of 1 year 10 months with thrombosis of the wall and increase in the perianeurysmal edema because of the progressive inflammatory process. Despite the successful endovascular treatment of aneurysm and best medical management, there is nonresolution of the perianeurysmal edema with haemorrhage in the wall of the aneurysm along with progressive worsening of the clinical symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Matsushima K, Kawashima M, Suzuyama K, Takase Y, Takao T, Matsushima T. Thrombosed giant aneurysm of the distal anterior cerebral artery treated with aneurysm resection and proximal pericallosal artery-callosomarginal artery end-to-end anastomosis: Case report and review ssof the literature. Surg Neurol Int 2011;2:135.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Carvi y Nievas MN. The influence of configuration and location of ruptured distal cerebral anterior artery aneurysms on their treatment modality and results: Analysis of our casuistry and literature review. Neurol Res 2010;32:73-81.  Back to cited text no. 2
    
3.
Sato Y, Samii M. A technique for sequential, progressive clipping for a giant thrombosed distal anterior cerebral artery aneurysm: Technical note. Surg Neurol Int 2017;8:292.  Back to cited text no. 3
  [Full text]  
4.
Krings T, Alvarez H, Reinacher P, Ozanne A, Baccin CE, Gandolfo C, et al. Growth and rupture mechanism of partially thrombosed aneurysms. Interv Neuroradiol 2007;13:117-26.  Back to cited text no. 4
    
5.
Kaneko T, Nomura M, Yamashima T, Suzuki M, Yamashita J. Serial neuroimaging of a growing thrombosed giant aneurysm of the distal anterior cerebral artery--case report. Neurol Med Chir (Tokyo) 2001;41:33-6.  Back to cited text no. 5
    
6.
Pahl FH, de Oliveira MF, Ferreira NP, de Macedo LL, Brock RS, de Souza VC. Perianeurysmal edema as a predictive sign of aneurysmal rupture. J Neurosurg 2014;121:1112-4.  Back to cited text no. 6
    
7.
Wallaert L, Soize S, De Beule T, Tomas C, Pierot L. Perianeurysmal edema: Prevalence, risk factors and clinical significance. J Journal of Neuroradiology 2017;44:135-42.  Back to cited text no. 7
    


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