‘Mickey mouse head aneurysms’ – Kissing aneurysms of the distal anterior cerebral artery: A case report and review of literature

Sachin Chemate; K Chandrasekar; C V Shankar Ganesh; Chetana Govindaraju; M Balamurugan

doi:10.4103/jcvs.jcvs_9_20

REVIEW ARTICLE

Year : 2020 | Volume : 8 | Issue : 1 | Page : 50-54

‘Mickey mouse head aneurysms’ – Kissing aneurysms of the distal anterior cerebral artery: A case report and review of literature

Sachin Chemate, K Chandrasekar, C V Shankar Ganesh, Chetana Govindaraju, M Balamurugan
Department of Neurosurgery, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Submission	10-Aug-2020
Date of Acceptance	01-Sep-2020
Date of Web Publication	1-Oct-2020

Correspondence Address:
Dr. Sachin Chemate
Department of Neurosurgery, Apollo Hospitals, Chennai, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcvs.jcvs_9_20

Abstract

When two or more adjacent intracranial aneurysms, arise from the same or different arteries, with separate origins and partially adherent walls, they are referred to as 'kissing aneurysms'. These are rare aneurysms. Among different locations of kissing aneurysms reported in the literature, kissing aneurysms of bilateral distal anterior cerebral arteries (DACAs), two different aneurysms situated symmetrically on opposite DACA are very rare. A 69-year-old woman with multiple comorbidities was admitted with anterior interhemispheric bleed. Magnetic resonance angiography and digital subtraction angiography (DSA) showed ruptured bilateral DACA aneurysms in mirror position to each other forming a Mickey mouse head appearance. The patient was managed surgically by craniotomy and clipping of both aneurysms. Kissing aneurysms of bilateral DACA aneurysms are very rare. DSA is essential to be useful for pre-operative diagnosis and planning. The basic principle of securing the parent artery proximally and clipping the neck after meticulous dissection should be followed.

Keywords: Digital subtraction angiography, distal anterior cerebral artery aneurysm, kissing aneurysm

How to cite this article:
Chemate S, Chandrasekar K, Ganesh C V, Govindaraju C, Balamurugan M. ‘Mickey mouse head aneurysms’ – Kissing aneurysms of the distal anterior cerebral artery: A case report and review of literature. J Cerebrovasc Sci 2020;8:50-4

How to cite this URL:
Chemate S, Chandrasekar K, Ganesh C V, Govindaraju C, Balamurugan M. ‘Mickey mouse head aneurysms’ – Kissing aneurysms of the distal anterior cerebral artery: A case report and review of literature. J Cerebrovasc Sci [serial online] 2020 [cited 2023 Mar 28];8:50-4. Available from: http://www.jcvs.in/text.asp?2020/8/1/50/296941

Introduction

'Kissing' aneurysms were initially defined and described by Jefferson^[1] in 1978. When two or more adjacent intracranial aneurysms, arise from the same or different arteries, with separate origins and partially adherent walls, they are referred to as 'kissing aneurysms'.^[1] They occur in <1% of all intracranial aneurysms.^[2] The most common site is the internal carotid artery, followed by the anterior communicating artery (ACom), distal anterior cerebral artery (DACA) and fenestrated basilar artery.^{[2],[3],[4],[5],[6],[7],[8]} Kissing aneurysms of bilateral DACAs are rare, and till date, only 12 case reports have been reported. We report one such case which was managed surgically by craniotomy and clipping of both aneurysms.

Case Report

A 69-year-old woman was admitted to the emergency department with complaints of one episode of sudden loss of consciousness lasting for 5–10 min, followed by headache. She was a known case of type II diabetes mellitus for 15 years and systemic hypertension for 10 years on regular management and previous history of well-differentiated squamous cell carcinoma of oesophagus diagnosed 5 years ago for which she underwent radiation and achieved remission. On examination, the patient was E4V4M6, vitals were stable, the pupil was normal sized and reacting to light and there were no focal neurological deficits. Due to previous history of carcinoma oesophagus and the patient's history, cerebral metastasis was suspected and magnetic resonance imaging brain was done, but surprisingly, it showed anterior interhemispheric bleed with corpus callosum haematoma [Figure 1]a and [Figure 1]b, and magnetic resonance angiography (MRA) of the brain was suggestive of two adjacent aneurysms on bilateral DACA at the junction of pericallosal and callosomarginal arteries [Figure 2]a. Digital subtraction angiography (DSA) was done, which showed two adjacent aneurysms over each DACA at the junction of pericallosal and callosomarginal arteries [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. Right-sided aneurysm was size 9.4 mm × 8.7 mm with a neck measuring 2.5 mm with a daughter lobule and superiorly projecting rupture site. Left-sided aneurysm measured size 7.6 mm × 5.5 mm with a neck of 2.5 mm. Both were directed anterosuperiorly. Both A1 ACAs were of the same size with good crossflow. Focal areas of segmental spasm were noted in the right pericallosal arteries [Figure 2]a, [Figure 2]b, [Figure 2]c.

Figure 1: (a and b) T2-weighted magnetic resonance imaging brain showing anterior interhemispheric bleed

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Figure 2: (a-c) Showing two adjacent aneurysms over each Distal Anterior Cerebral Artery

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Figure 3: Showing two mirror Distal Anterior Cerebral Artery aneurysms

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The patient underwent surgery; right frontal craniotomy was done. Anterior interhemispheric approach was utilised. With the help of navigation [Figure 4], the pericallosal and callosomarginal arteries of the left side were identified and traced proximally. Right DACA aneurysm arising from the junction of pericallosal and callosomarginal artery directing anterosuperiorly was visualised [Figure 5]a and [Figure 5]b. Temporary proximal clip was applied over right A2 and right DACA aneurysm was clipped. Left DACA aneurysm was identified. It was buried in the brain parenchyma with overlying haematoma and adhesions. Proximal control over the right A2 achieved with temporary clip. While dissecting the dome of aneurysm, there was intraoperative rupture, which was managed with bipolar cautery and permanent clip applied at the neck of right DACA aneurysm. Intraoperative indocyanine green dye showed patent proximal and distal DACA, both the aneurysms were completely secured and there was no residual neck [Figure 5]c.

Figure 4: Navigation system showing aneurysm (green dot) pointed by white arrow

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Figure 5: Intra-operative images showing mirror Distal Anterior Cerebral Artery aneurysms

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Minimal brain retraction was used. Postoperatively, the patient was extubated immediately. Postoperatively, the patient had no new deficit. As our institutional protocol, the patient was managed with triple-H therapy. Computed tomography (CT) brain was done on post-operative day 1, which showed no evidence of infarct or haemorrhage [Figure 6]a and b]. The patient was discharged on post-operative day 7 without any neurological deficit.

Figure 6: (a and b) Computed tomography brain showing clips applied on both distal anterior cerebral artery aneurysms

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Discussion

Epidemiology

DACA aneurysms have been reported to have an average incidence of 4.4%^.[9] Bilateral DACA 'mirror image aneurysms' are extremely rare,^{[2],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]} with majority of reports from Japanese literature [Table 1].

Table 1: Review of literature on mirror DACA aneurysms

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Pathophysiology

Laitenen and Snellman^[21] postulated that a supreme ACom, a bridging artery located at the bifurcation of A2 into the pericallosal and callosomarginal arteries and other embryological connections like azygos ACA and triple ACAs might represent an embryological remnant and lead to flow disturbance in anterior cerebral artery bifurcation causing bilateral, symmetrical aneurysms. However, no vascular anomaly was detected in our case. Yasargil and Carter^[22],[23] treated 13 patients with DACA aneurysms with microsurgical techniques and found that there were two cases where the aneurysmal sacs were connected. Based on this, they suggested that some embryological variations, such as a supreme ACoA, may cause a flow disturbance leading to aneurysm formation. Jefferson^[1] suggested a hereditary basis for pathogenesis of bilateral DACA aneurysm, but it still remains unclear. Wanifuchi et al.^[24] described female dominance of bilateral DACA aneurysm, but other multiple aneurysms also have a higher frequency in females.

Diagnosis

CT angiography, MRA and DSA are most useful for the diagnosis of bilateral DACA aneurysms. Although MRA is very sensitive and specific for distal aneurysm and three-dimensional reconstructions are also available in this imaging, DSA provides a complete study of intracranial vessels in real time. Vasospasm can also be diagnosed during angiogram in early phases. Other distal incidental aneurysms can be seen in angiograms. It also gives very critical information regarding aneurysm location, shape, size of the neck, branch vessel and cross circulation, which helps a surgeon to decide whether to go for clipping or coiling.

Management

The most definite management at the bilateral DACA aneurysm is clipping the aneurysm. Bilateral DACA aneurysm has a tendency to rupture, so it presents with subarachnoid haemorrhage and anterior interhemispheric haematoma. The incidence of rebleed is also very high in DACA aneurysm. Through anterior interhemispheric approach, we cannot only achieve a proximal control on A2 and secure the aneurysm, but also it provides an access evacuation of for haematoma and mass effect, and thorough washing of the cranial cavity with normal saline during surgery also removes blood by-products, which decreases the intensity and duration of vasospasm. Aneurysm occlusion rate is very high with clipping, and rebleeding or recurrence is very rare after clipping. Challenges of craniotomy and clipping are narrow working corridor, oedematous brain, adhesions and buried dome of aneurysm in the surrounding brain parenchyma. The dome of the aneurysms is always directed towards the surgeon, and proximal A2 is inferior to aneurysm when visualised from working corridor; hence, proximal control is a challenge and the chance of intraoperative rupture is high. Only one case report is available in the literature about the experience of coiling.

Our patient was taken up for clipping after angiogram. During the operative procedure, retraction was applied first on the right medial frontal lobe. The parent artery and dome of left aneurysm were identified. The dome was followed inferiorly up to the neck, and the clip was applied on proximal A2. After securing left-sided aneurysm completely, right-sided A2 proximal clip was applied. The dome and neck of the right DACA aneurysm were then dissected and the clip was applied. However, while dissecting the aneurysm, aneurysm ruptured in spite of temporary clip on proximal A2. Recurrent use of temporary clips loses their occlusion force resulting in only partial occlusion. Intraoperative rupture was managed with bipolar cautery over the dome and multiple clipping over the bleb. After securing the bleb rupture, the final clip was applied at the neck.

Conclusion

DSA is essential for the diagnosis of multiple intracranial aneurysms. Mirror images of bilateral DACA aneurysms are very rare. They are a specific type of aneurysms with probably derived from embryological rearmament. The basic surgical strategy of securing the parent artery and clipping the neck after meticulous dissection of each aneurysm separately is key for successful clipping of aneurysm, as the chance of intraoperative rupture is very high.

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.

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