Anterior cerebral artery - Anatomic region favoring aneurysms: Case series

Anterior cerebral artery aneurysm

International Archives of Integrated Medicine, Vol.

Copy right © 2014, IAIM, All Rights Reserved.

Case Series

Anterior cerebral artery

favoring

Ashfaq ul Hassan

Masood Tanver4, Obaid

1Lecturer, Clinical Anatomy, Sher2Tutor, Clinical Anatomy, Sher

3Professor, Department of Medicine, SMHS Hospital, Srinagar, Kashmir, India

4Professor, Department of Medici

5Department of Radiology, Sher

6Physician, Directorate of Health Services, Srinagar, Kashmir, India7Medical Consultant, IUST, Awantipora, Srinaga

*Corresponding author’s email:

How to cite this article: Ashfaq ul Hassan, Rohul Afza Kaloo

Muneeb ul Hassan, Zahida Rasool.

Case series. IAIM, 2014; 1(3): 31

Available online at

Received on: 21-10-2014

Abstract

Aneurysms or Dilatations in the vessels

arteries at the base of brain. Rupture occurs into the s

into parenchyma of the brain. 80

are the Berry’s aneurysms and commonest sites ar

with anterior cerebral artery and

Key words

Anterior cerebral artery, Aneurysm, Callosum, Terminal.

Introduction

These aneurysms may undergo small ruptures

and bleed (sentinel bleeds). Sudden unexplained

headaches should raise suspicion of s

arachnoid hemorrhage (SAH)

investigated because major hemorrhage

imminent and life consuming.


International Archives of Integrated Medicine, Vol. 1, Issue. 3, November, 2014.


Anterior cerebral artery - Anatomic region

favoring aneurysms: Case series

Ashfaq ul Hassan1*

, Rohul Afza Kaloo2, Pervez Shah

, Obaid5, Muneeb ul Hassan

6, Zahida Rasool

Lecturer, Clinical Anatomy, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India

Tutor, Clinical Anatomy, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India

Professor, Department of Medicine, SMHS Hospital, Srinagar, Kashmir, India


Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir,

Physician, Directorate of Health Services, Srinagar, Kashmir, India

Medical Consultant, IUST, Awantipora, Srinagar, Kashmir, India

*Corresponding author’s email: [email protected]

Ashfaq ul Hassan, Rohul Afza Kaloo, Pervez Shah, Masood Tanver, Obaid,

, Zahida Rasool. Anterior cerebral artery - Anatomic region

31-35.

Available online at www.iaimjournal.com

2014 Accepted on:

Aneurysms or Dilatations in the vessels which are prone to rupture occur at bifurcations o

of brain. Rupture occurs into the sub-arachnoid space in the basal cisterns and

80-90% of these aneurysms occur at circle of Willis. Commonest types

ysms and commonest sites are at Junction of anterior communicating artery

nd bifurcation of middle cerebral artery.

Anterior cerebral artery, Aneurysm, Callosum, Terminal.

may undergo small ruptures

). Sudden unexplained

should raise suspicion of sub-

and should be

hemorrhage may be

Case series

Case - 1

A 45 years old woman presented in

Department with sudden onset headache,

dizziness and neck pain. There was no past

history of hypertension, diabetes

patient was able to move her extremities.

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Page 31

Anatomic region

aneurysms: Case series

, Pervez Shah3,

, Zahida Rasool7

Srinagar, Kashmir, India



ne, SMHS Hospital, Srinagar, Kashmir, India


Physician, Directorate of Health Services, Srinagar, Kashmir, India

r, Kashmir, India

[email protected] , Pervez Shah, Masood Tanver, Obaid,

Anatomic region favoring aneurysms:

Accepted on: 28-10-2014

occur at bifurcations of large

arachnoid space in the basal cisterns and

of these aneurysms occur at circle of Willis. Commonest types

Junction of anterior communicating artery

old woman presented in Emergency

tment with sudden onset headache,

nd neck pain. There was no past

story of hypertension, diabetes, pyrexia. The

as able to move her extremities.




Cranial nerves were normal on examination

brain stem reflexes were normal. CT angiogram

showed an aneurysm in the area of Circle of

Willis in anterior circulation within the anterior

cerebral artery. (Photo – 1, Photo

3)

Photo – 1: CT angiogram showing aneurysm of

anterior cerebral artery (Case – 1)



Case - 2

A 40 years old woman presented

Department with severe headache

vomiting, dizziness and transient loss of

consciousness. There was no past history of

hypertension and diabetes. Patient w

move her extremities. Cranial ner

normal on examination and brain stem r

were normal. 3D CTA (CT angiogram) showed an




rves were normal on examination and

brain stem reflexes were normal. CT angiogram

in the area of Circle of

anterior circulation within the anterior

1, Photo – 2, Photo –

CT angiogram showing aneurysm of

1)


1)

s old woman presented in Emergency

Department with severe headache, projectile

vomiting, dizziness and transient loss of

consciousness. There was no past history of

atient was able to

Cranial nerves were

brain stem reflexes

3D CTA (CT angiogram) showed an

aneurysm in the area of Circle

anterior circulation within the a

artery. (Photo – 4)


anterior cerebral artery (Case

Photo – 4: 3D CTA showing aneurysm of anterior

cerebral artery (Case – 2)

Discussion

Neuro-anatomy of anterior cerebral artery

The brain receives its blood supply from two

main sources:

A. The internal carotid arteries

from the common carotid arteries).

B. The vertebral arteries

the subclavian arteries).

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Page 32

he area of Circle of Willis in

anterior circulation within the anterior cerebral



3D CTA showing aneurysm of anterior

anatomy of anterior cerebral artery

The brain receives its blood supply from two

internal carotid arteries (which arise

from the common carotid arteries).

The vertebral arteries (which arise from

arteries).




Anterior cerebral artery is the “

two terminal branches of the internal carotid

artery. It passes “medially

towards the middle line and then turns sharply

“upwards” in the longitudinal fissure to reach

the genu of the corpus callosum; it then runs

“backwards” along the upper surface of the

corpus callosum to reach the splenium where

ends by turning “upwards” anterior to the

parieto-occipital sulcus. Branches of the anterior

cerebral artery are [1, 2]

1. Cortical branches and

2. Central branches which

supply the anterior part of the corpus

striatum and part of the anterior limb of

the internal capsule.

3. Branches to the septal region

septum lucidum.

4. Branches to all parts of the corpus

callosum except the splenium

supplied by the posterior cerebral

artery).

Clinical importance of the anterior cerebral

artery lies in the fact that it supplies 3 important

regions on the medial surface:

a. The motor and sensory areas of the

“lower limb” (in the paracentral lobule).

b. The septal region (where a small lesion

may result in prolonged

unconsciousness).

c. The corpus callosum: Apraxia may result

from a lesion to the corpus callosum

The vessel is divided into A1 (between carotid

bifurcation and anterior communicating artery)

A2 (from rostrum to genu of corpus callosum)

and A3 segments (around the genu of corpus

callosum).

Physiological aspects of blood flow

The grey matter contains more capillaries than

the white matter (needs more oxygen).

arterial blood pressure (and especially the




erebral artery is the “smaller” of the

two terminal branches of the internal carotid

and forwards”

towards the middle line and then turns sharply

“upwards” in the longitudinal fissure to reach

the corpus callosum; it then runs

” along the upper surface of the

corpus callosum to reach the splenium where it

ends by turning “upwards” anterior to the

Branches of the anterior

which penetrate to

supply the anterior part of the corpus

striatum and part of the anterior limb of

Branches to the septal region including

Branches to all parts of the corpus

t the splenium (which is

the posterior cerebral

Clinical importance of the anterior cerebral

it supplies 3 important

The motor and sensory areas of the

paracentral lobule).

(where a small lesion

may result in prolonged

: Apraxia may result

from a lesion to the corpus callosum [3].

(between carotid

r communicating artery),

ostrum to genu of corpus callosum)

nd the genu of corpus

lood flow

The grey matter contains more capillaries than

the white matter (needs more oxygen). The

arterial blood pressure (and especially the

difference between the arterial and venous

blood pressure) is the main factor in regulating

the volume of blood flow to the brain. More

than 25% of the blood circulates in the human

brain at rest. At rest also, about 25% of the

oxygen inspired is absorbed by the brain.

Glucose is the principal substance oxidized by

the brain. Unconsciousness develops 5

seconds after sudden stoppage of blood flow to

the head.

Pathological considerations

The anterior circulation is notorious for

aneurysm formation. Aneurysms may remain

clinically silent or may present with varied

symptoms like severe onset headache, vomiting,

neck pain, loss of consciousness or focal neuro

deficit depending on the site of leakage. Most of

them occur in the territory of anterior and

middle cerebral artery. The cerebral and dural

arteries have the following characteristics

• Thin walls when compared to their

lumen.

• Very well developed internal elastic

lamina.

• Few smooth muscle fibers.

Histologically, the arteries form the main

components of the vascular system. On the

whole, the general arrangement of a medium

sized vessel has 3 layers from within outwards

which are tunica intima, tunica media

adventitia. Cerebral vessels have

tunica media and very little

tunica externa. There are minimal defects or

gaps in media called locus minoris resistentiae

which are major risk factors for development of

aneurysms. Also the location of cerebral

aneuryms favors sites of bifurcation of vessels

where disturbances of cerebral blood flow

generated. At these areas there is more

turbulence and more chance of endothelial

damage which has been proven to be a nidus for

aneurysm formation. This fact can be made

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Page 33

difference between the arterial and venous

blood pressure) is the main factor in regulating

the volume of blood flow to the brain. More

than 25% of the blood circulates in the human

o, about 25% of the

oxygen inspired is absorbed by the brain.

Glucose is the principal substance oxidized by

the brain. Unconsciousness develops 5-10

seconds after sudden stoppage of blood flow to

Pathological considerations

lation is notorious for

aneurysm formation. Aneurysms may remain

clinically silent or may present with varied

t headache, vomiting,

, loss of consciousness or focal neuro

deficit depending on the site of leakage. Most of

hem occur in the territory of anterior and

The cerebral and dural

arteries have the following characteristics:

Thin walls when compared to their

Very well developed internal elastic

Few smooth muscle fibers.

he arteries form the main

components of the vascular system. On the

the general arrangement of a medium

sized vessel has 3 layers from within outwards

unica media and tunica

ventitia. Cerebral vessels have less marked

tunica media and very little elastic tissue in

rna. There are minimal defects or

gaps in media called locus minoris resistentiae

are major risk factors for development of

aneurysms. Also the location of cerebral

sites of bifurcation of vessels

urbances of cerebral blood flow are

generated. At these areas there is more

turbulence and more chance of endothelial

damage which has been proven to be a nidus for

aneurysm formation. This fact can be made




worse by associated atherosclerosis

to disturbances in laminar flow.

Pathologically, congenital defects in the muscle

and elastic tissue of the arterial med

deteriorate as they are exposed over time to the

hemodynamic stresses of pulsat

The types of aneurysms are saccular o

Endogenous factors like altered bloo

elevated blood pressure, germ line mutations,

endothelial repair defects contribute.

A modest incidence of familial saccular

aneurysms as well as their association with

polycystic kidney disease, Ehlers

syndrome, Marfans syndrome, Coarctation of

aorta, Bicuspid valvular disease,

Neurofibromatosis, Fibromuscular dysplasia,

Autosomal polycystic kidney d

and other connective tissue disorders implicates

hereditary factors. Although hypertension is not

a significant risk factor for aneurysmal SAH,

aneurysms have been known to rupture under

conditions associated with a sudden rise in

blood pressure, including extremes of emotional

excitement and physical exertion such as heavy

exercise, coitus and athletic events.

rupture is a serious complication

rupture is directly correlated with the size of

aneurysm.

Radiographic assessment

The risk of rupture significantly increases

sizes greater than 6 mm [7]. Aneurysms with a

daughter sac are also more liable to rupture. The

pathogenesis of aneurysms reflects a

combination of congenital, acquired, and

hereditary factors.

The assessment of aneurysms also requires

detailed radiological procedure which can

delineate and determine the exact size along

three axis, the maximal width of the neck of

aneurysm, lobulations, orientation and vascular




by associated atherosclerosis which leads

ongenital defects in the muscle

and elastic tissue of the arterial media gradually

deteriorate as they are exposed over time to the

hemodynamic stresses of pulsatile blood flow.

neurysms are saccular or fusiform.

like altered blood flow,

germ line mutations,

endothelial repair defects contribute.

A modest incidence of familial saccular

aneurysms as well as their association with

polycystic kidney disease, Ehlers-Danlos

Marfans syndrome, Coarctation of

alvular disease,

ibromuscular dysplasia,

Autosomal polycystic kidney disease [4, 5, 6]

d other connective tissue disorders implicates

hereditary factors. Although hypertension is not

a significant risk factor for aneurysmal SAH,

aneurysms have been known to rupture under

conditions associated with a sudden rise in

xtremes of emotional

excitement and physical exertion such as heavy

exercise, coitus and athletic events. Aneurismal

ture is a serious complication and risk of

rrelated with the size of

upture significantly increases with

neurysms with a

daughter sac are also more liable to rupture. The

pathogenesis of aneurysms reflects a

combination of congenital, acquired, and

eurysms also requires

detailed radiological procedure which can

delineate and determine the exact size along

three axis, the maximal width of the neck of

, orientation and vascular

profile of any smaller branch arising from the

aneurysm. CT scans reveal sub

within the basal cisterns in about three quarters

of patients within 48 hours of bleeding.

Magnetic resonance (MR) images

CT Scans have a lower index of accuracy.

Detection of intracranial blood on the CT scan

localized to the basal cisterns, the sylvian

fissure, or the intra-hemispheric fissure more

indicates rupture of a saccular aneurysm.

Cerebral angiography remains the definitiv

study to detect the source of SAH.

therapy for a ruptured saccular aneurysm

consists of surgical clipping of the aneurysm to

prevent re-bleeding. Medical therapy aims to

reduce the risk of re-bleeding and cerebral

vasospasm and to prevent

complications before and after surgical

intervention. Digital Subtraction Angiography is

now performed in most of the centres of the

world and is particularly specific for aneu

Multi-detector CT angiography (

replaced the Digital Subtraction A

many places in view of being more non invasive,

with higher sensitivity and specificity

11, 12, 13]. It offers complete anatomic details

and has faster scanning options.

Conclusion

The aneurysms can rupture and

significant morbidity and mortality. A simple

headache can be a presentation of this deadly

pathological entity which simulates a time

bomb. Every physician should rule out

possibility of underlying aneurysm.

References

1 Bracard S., Roland J., Picard L. Les

vaisseaux du névraxe: Anatomie et

pathologie. Livre 1

artères de l’encéphale Aulnay sous Bois:

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Page 34

profile of any smaller branch arising from the

CT scans reveal sub-arachnoid blood

within the basal cisterns in about three quarters

of patients within 48 hours of bleeding.

Magnetic resonance (MR) images in contrast to

have a lower index of accuracy.

Detection of intracranial blood on the CT scan

localized to the basal cisterns, the sylvian

hemispheric fissure more

indicates rupture of a saccular aneurysm.

Cerebral angiography remains the definitive

study to detect the source of SAH. The definitive

therapy for a ruptured saccular aneurysm

consists of surgical clipping of the aneurysm to

bleeding. Medical therapy aims to

bleeding and cerebral

vasospasm and to prevent other medical

complications before and after surgical

intervention. Digital Subtraction Angiography is

st of the centres of the

and is particularly specific for aneurysms.

detector CT angiography (MD CTA) has

raction Angiography at

being more non invasive,

with higher sensitivity and specificity [8, 9, 10,

complete anatomic details

has faster scanning options.

The aneurysms can rupture and bleed causing

significant morbidity and mortality. A simple

headache can be a presentation of this deadly

pathological entity which simulates a time

hysician should rule out the

neurysm.

S., Roland J., Picard L. Les

eaux du névraxe: Anatomie et

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Source of support: Nil

Conflict of interest: None declared.

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None declared.

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Anterior cerebral artery - Anatomic region favoring aneurysms: Case series