Elsevier

World Neurosurgery

Volume 105, September 2017, Pages 1032.e19-1032.e22
World Neurosurgery

Case Report
Ruptured Distal Anterior Choroidal Artery Aneurysm Treated with Superselective Provocative Testing and Coil Embolization

https://doi.org/10.1016/j.wneu.2017.05.176Get rights and content

Background and Importance

Aneurysms of the anterior choroidal artery are uncommon, and distal anterior choroidal artery aneurysms are even rarer, with only 34 cases reported in the medical literature. These lesions have been most commonly reported in association with moyamoya disease or arteriovenous malformations. Most published experience with these aneurysms involves open surgical approaches. Reports of endovascular treatment have been in patients with lesions distal to the plexal point and have employed vessel occlusion with liquid embolic agents in preference to coil embolization.

Clinical Presentation

We present a case of a ruptured distal anterior choroidal artery aneurysm located on the cisternal segment of the artery. This lesion was successfully treated with endovascular coil embolization. Additionally, the patient underwent pre-embolization superselective provocative testing with amobarbital to assess the safety of parent vessel occlusion.

Conclusion

Endovascular coil embolization for distal anterior choroidal artery aneurysms is technically feasible and may be preferable to embolization with liquid embolic agents for lesions proximal to the plexal point. This case illustrates the utility of provocative testing and efficacy of endovascular coil embolization for lesions in this unique location.

Section snippets

Background and Importance

Aneurysms of the anterior choroidal artery are uncommon, and those located on the distal aspect of this artery are even rarer, with only 34 cases reported in the medical literature, 16 of which were associated with moyamoya disease.1 Presentation often includes intracerebral hemorrhage, though subarachnoid hemorrhage has been reported for aneurysms of the cisternal segment.2 These lesions have been most commonly reported in association with vascular disease or arteriovenous malformations.3, 4

History

A 40-year-old man was transferred to our center with the acute onset of a thunderclap headache with associated nausea and vomiting. Symptoms began immediately following orgasm, as has been previously reported.10 Medical history was notable for asthma and scoliosis, corrected surgically. Social history was notable for occasional alcohol use but negative for the use of tobacco or other drugs. There was no family history of aneurysms or vascular disease.

Examination

Upon examination the patient was afebrile

Discussion

The anterior choroidal artery arises from the posterior wall of the internal carotid artery and travels in the subarachnoid space before entering the lateral ventricle by piercing the choroidal fissure. Before entering the choroidal fissure, the anterior choroidal artery gives off multiple perforators to the posterior limb of the internal capsule, optic tracts, lateral thalamus, and globus pallidus. Distal to the plexal point occlusion is usually inconsequential, though large and important

Conclusions

Distal anterior choroidal aneurysms are uncommon lesions that can be challenging to treat. They often occur in association with high-flow conditions, such as moyamoya disease and arteriovenous malformations, but can occur in isolation. Endovascular treatment with coil embolization is feasible and offers favorable outcomes in limited reports. Neurointerventionalists treating aneurysms of the distal anterior choroidal artery and similar lesions requiring occlusion of a critical vessel should

References (13)

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    However, there is potential for reflux in the setting of liquid embolization agent occluding the proximal AChA and associated perforators. With these concerns in mind Schmalz et al. successfully employed coil embolization in a patient without MMS who presented with a distal AChA aneurysm located proximally to the plexal point [20]. Furthermore, despite which operative route is used whether it be surgical or endovascular, two important factors that drive the success of intervention in the treatment of moyamoya distal AChA aneurysms are the aneurysm location and preservation of the parent artery especially when the aneurysm is in the trigone of the lateral ventricle [2].

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Conflict of interest statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare neither personal nor institutional conflicts of interest.

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