ACOM ANEURYSM

1. ACOM ANEURYSM BY:
DR. ANAS AHMED

2. OUTLINES
• INTRODUCTION
• ANATOMY
• CAUSES
• CLINICAL
• INVESTIGATIONS
• MANAGEMENT

3. INTRODUCTION
• Anterior communicating artery is the most common site for
aneurysms
• These aneurysms are clinically silent until they rupture
• They can produce symptoms due to subarachnoid hemorrhage or
due to mass effect
• There are 2 types of aneurysms
• Saccular
• Fusiform

4. ANATOMY
• Anterior communicating artery communicate two anterior cerebral
arteries
• A1 segment of the Anterior cerebral artery runs from internal carotid
artery to anterior communicating arteries
• The junction of A1 and anterior communicating artery lies over optic
chiasm in 70% cases while over optic nerve in 30% of cases
• Rarely A1 segment is replaced by artery arising from carotid at level
of anterior clinoid and passes under ipsilateral optic nerve perceived
as misplaced A1 segment and this anomaly is strongly associated
with aneurysm
• Cholinergic nuclei are located in paraolfactory area and around the
inferior third ventricle which function in memory and arousal and are

5. • Anterior communicating artery gives perforating branches to lamina
terminalis, anterior hypothalamus, septal nucleus, medial
paraolfactory nuclei, subcallosal cingulum and genu of corpus
callosum
• Two larger branches are subcallosal and medial callosal arteries

10. CHARECTERISTICS OF
ANEURYSM
• Size of ACOM aneurysm
• <6 mm (20%)
• 6-10 mm (55%)
• 11-25 mm (25%)
• >25 mm (very rare)
• Origin of ACOM aneurysm
• 70 to 80% aneurysms arise from junction of ACOM and anterior cerebral artery
• 85 to 97% arise from dominant A1 vessel side
• Direction
• Downward (10-15%) adherent to optic chiasm or tuberculum sellae, obscure
opposite A1
• Upward (35-60%) adherent to A2, fronto orbital or fronto polar arteries
• Forward (20-25%) adherent to optic chiasm or tuberculum sellae, obscure opposite
A1
• Posterior (8-15%) adherent to perforating vessels

16. CAUSES
• SACCULAR ANEURYSMS
• Hemodynamic
• Uneven pulsatile pressure
• Increased flow
• Increased blood pressure
• Structural
• Combined media and elastica defects
• Preaneurysmal lessions
• Genetic
• Familial intracranial aneurysm syndrome
• Ehlers-Danlos syndrome, Marfan syndrome, type III collagen deficiency
• Traumatic
• Skull fractures
• Penetrating foreign bodies
• Surgical injuries

17. • Infectious
• Bacterial
• Fungal
• Neoplastic
• Metastatic
• Primary Neoplasms
• Aneurysms associated with neoplasms
• Radiation
• Others
• Granulomatous angitis
• Systemic Lupus erythematosus
• Moyamoya disease
• Sickle cell anemia

18. • FUSIFORM ANEURYSMS
• Atherosclerosis
• Structural
• Long areas of loss of elastica and media
• Diffuse fibromuscular dysplasia
• Genetic
• Marfan’s syndrome, pseudoxanthoma elasticum
• Infectious
• Syphilis
• Hemodynamic
• Coaractation of aorta
• Radiations
• Others
• Giant cell artritis

19. CLINICAL
• Ruptured Aneurysm
• Meningism
• Coma
• Nausea and vomiting
• Headache
• Neurological deficit
• Dysphasia
• Homonymous hemianopia
• Third nerve palsy

20. • Unruptured aneurysm
• Headache
• Visual loss
• Hormonal imbalance
• Personality changes
• Thrombo-embolism
• Seizures
• Focal neurological deficits

21. INVESTIGATIONS
• CT scan
• CT angiogram
• MRI and MRA
• DSA

31. MANAGEMENT
• GENERAL MANAGEMENT
• Hemodilution
• Hypervolumia
• Hypertention
• Hydrocephalus
• Seizures
• Compression stockings
• Calcium channel blockers

32. MANAGEMENT
• SPECIFIC MANAGEMENT
• Clipping
• Pterional approach
• Bifrontal approach
• Coilling

34. MANAGEMENT
• Advantages of early surgery
• Eliminates chances of rehemorrhage
• Removes clots, decreasing chances of vasospasm
• Allows hypertensive and endovascular treatment of vasospasm
• Prevents complication s of bed rest
• Soft clot easier to dissect
• Shorten hospital stay
•Advantages of delayed surgery
• Improved hemodynamic status of brain
• Brain slack
• Proven excellent surgical results

49. COMPLICATIONS
• Aneurysmal Rupture
• Damage to temporal lobe
• Nerve injury
• Artery injury
• CSF leak
• Hemtoma
• Memory loss
• Personality changes
• Visual loss
• Endocrine disturbance