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- 1. ACOM ANEURYSM BY: DR.ANAS AHMED
- 2. OUTLINES • INTRODUCTION • ANATOMY •CAUSES • CLINICAL • INVESTIGATIONS • MANAGEMENT
- 3. INTRODUCTION • Anterior communicatingartery 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 communicatingartery 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 communicatingartery 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 • Sizeof 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 ofearly 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