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| CASE REPORT |
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| Year : 2020 | Volume
: 8
| Issue : 2 | Page : 134-136 |
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Kissing aneurysms of the internal carotid artery
Amit Kumar Sharma, Anita Jagetia, Arvind Kumar Srivastava, Daljit Singh
Department of Neurosurgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi, India
| Date of Submission | 23-Aug-2020 |
| Date of Acceptance | 31-Aug-2020 |
| Date of Web Publication | 3-Feb-2021 |
Correspondence Address:
Dr. Amit Kumar Sharma
Department of Neurosurgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | 3 |
DOI: 10.4103/jcvs.jcvs_17_20
Kissing aneurysms (KAs) are rare and cause various problems when clipping of these aneurysms is attempted because they often partially adhere to each other. A 65-year-old female presented with subarachnoid haemorrhage due to a ruptured aneurysm originating from the left internal carotid artery (ICA)-posterior communicating artery A. She also had an unruptured aneurysm arising from the bifurcation of a left ICA-anterior choroidal artery A. Intraoperative findings revealed that these were KAs. Surgical clipping was performed. The postoperative period was uneventful. In this case report, we would like to stress the rarity of KAs and the difficulty in the diagnosis and management of such cases.
Keywords: Anterior choroidal artery, internal carotid artery, kissing aneurysm, posterior communicating artery
How to cite this article:
Sharma AK, Jagetia A, Srivastava AK, Singh D. Kissing aneurysms of the internal carotid artery. J Cerebrovasc Sci 2020;8:134-6 |
How to cite this URL:
Sharma AK, Jagetia A, Srivastava AK, Singh D. Kissing aneurysms of the internal carotid artery. J Cerebrovasc Sci [serial online] 2020 [cited 2023 Feb 4];8:134-6. Available from: http://www.jcvs.in/text.asp?2020/8/2/134/308626 |
| Introduction | |  |
Kissing aneurysms (KAs) are caused when two aneurysms with different necks mutually contact each other, which was first reported by Jefferson in 1978.[1] In 1984, Yasargil[2] named these aneurysms KAs. They are relatively rare, earlier reported with an overall incidence of 0.2%–0.9% of all cerebral aneurysms, and it is observed that posterior communicating aneurysms and anterior choroidal aneurysms are the most common in reported literature.[2] As KAs occur in arteries with adherent walls, there is always a risk of it being misdiagnosed as a single aneurysm, resulting in a wrong treatment option, which could potentially lead to the subsequent intraprocedural rupture of the aneurysms.[3]
| Case Report | | |
A 65-year-old female presented with sudden-onset severe headache and presented to our institute on day 2 of onset. There was no episode of altered consciousness and no motor weakness. Neurological evaluation at admission revealed a blood pressure of 145/92 mmHg, Hunt-Hess Grade-2, and the rest was unremarkable. Cranial computed tomography (CT) revealed subarachnoid haemorrhage (SAH) in the interhemispheric fissure, bilateral Sylvian fissure and basal cisterns [Figure 1]a, and cerebral CT angiography demonstrated a wide-neck bilobed aneurysm in the left internal carotid artery (ICA)-posterior communicating artery (Pcomm artery [Pcomm A] region directing posterolaterally) [Figure 1]b. The patient underwent left pterional craniotomy, and clipping of the aneurysm was done. The two aneurysms were seen arising from the lateral wall of the ICA just proximal to ICA bifurcation, with their neck adhered to each other; it was extremely difficult to dissect the space between them. These KAs consisted of an ICA-Pcomm A aneurysm and an ICA-anterior choroidal artery (ICA-Ach A) aneurysm [Figure 2]a and [Figure 2]b, and the ICA-Pcomm A aneurysm was appeared to have ruptured, as also shown in [Figure 3]. A single permanent clip was applied along the wall of the ICA to occlude the neck of both aneurysms. Both the Pcomm A and Ach A were secured. | Figure 1: (a) Non-contrast computed tomography brain showing blood in the interhemispheric fissure, bilateral Sylvian fissure and basal cistern. (b) Cerebral computed tomography angiogram brain showing a possible wide-neck, bilobed internal carotid artery-posterior communicating artery aneurysm
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 | Figure 2: (a) Intraoperative image showing internal carotid artery-posterior communicating and internal carotid artery-anterior choroidal artery aneurysm with adjacent neck over the internal carotid artery. (b) Intraoperative image after clipping of aneurysm, both posterior communicating artery and anterior choroidal artery can be visualised
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 | Figure 3: Schematic diagram showing the aneurysms with adherent neck wall
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| Discussion | | |
KAs are a rare type of multiple aneurysms that have been described in literature as two aneurysms which are anatomically adjacent but with separate origins and with partially adherent neck or wall at the site of origin.[1] In this case report, we aim to highlight the rarity of the KAs of this area. The ICA has been reported to be the most common site for KAs, but only few cases of ICA KAs, including the present case, have been reported since first described in literature.[1],[2],[4],[5],[6],[7],[8],[9] Second, there is difficulty in diagnosing these aneurysms preoperatively. As described in previous reports, it is not easy to diagnose these aneurysms preoperatively as they appear to be multiloculated angiographically. Therefore, the possibility of KAs must be considered in the case of aneurysm with wide neck and multiloculated, especially lobules at the junction of origin and parent artery.[1],[6],[10] In most cases, ICA-PcomA aneurysm is larger than the ICA-AchA aneurysm[4] and SAH is commonly due to the rupture of the former.[1] Our findings are consistent with those of the previous reports. In those reports, standard microsurgical clipping was used for all patients except one case for which endovascular management was used. The complicated anatomy of aneurysms and the perplexing anatomical relationship of these adjacent aneurysms and vessels often makes the diagnosis and treatment a challenge, especially for young neurosurgeons. Thus, describing this case again signifies the importance to discuss how to suspect these KAs, hence to prevent pre-mature intraoperative rupture during aneurysm dissection, and choosing appropriate treatment (microsurgical/endovascular) and how to clip and occlude the aneurysms completely without obliteration of the ICA, PcomA and AchA is of paramount importance for good outcome.
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 | | |
| 1. | Jefferson A. The significance for diagnosis and for surgical technique of multiple aneurysms of the same internal carotid artery. Acta Neurochir (Wien) 1978;41:23-37.  |
| 2. | Yasargil MG: Microneurosurgery: Clinical Considerations, Surgery of the Intracranial Aneurysms and Results (Microsurgical Anatomy of Basal Cisterns & Vessels of Brain) Vol. 2. Stuttgart, Germany: Thieme; 1984. p. 33-23. |
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| 8. | Shioya H, Kikuchi K, Suda Y, Shoji H, Shindo K. Ruptured internal carotid -posterior communicating artery aneurysm associated with an anomalous hyperplastic anterior choroidal artery and aneurysm: Case report. No Shinkei Geka 2005;33:155-62. |
| 9. | Takahashi C, Kubo M, Okamoto S, Matsumura N, Horie Y, Hayashi N, et al. “Kissing” aneurysms of the internal carotid artery treated by coil embolization. Neurol Med Chir (Tokyo) 2011;51:653-6. |
| 10. | Wanifuchi H, Tanikawa T, Iseki H, Muragaki Y, Ishizaki R, Takakura K. Kissing aneurysms between the internal carotid artery and the anterior communicating artery: A case report. Jpn J Neurosurg ( Tokyo )1998;7:694-8. |
[Figure 1], [Figure 2], [Figure 3]
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