The anterior choroidal artery (AChA) is one of the main arteries, and it can exhibit several anomalies, among which is the common origin of the AChA and posterior communicating artery (PcomA); however, this is relatively rare. In the case that the AChA originates from the PcomA, it is highly uncommon for a concomitant aneurysm to develop at the internal carotid artery (ICA)-PcomA junction. The present study reports such a case. A 58-year-old female developed a headache with nausea and vomiting. Computed tomography (CT) revealed a subarachnoid hemorrhage. CT angiography and digital subtraction angiography (DSA) revealed a right ICA-PcomA aneurysm, with the AChA arising from the proximal segment of the PcomA. The aneurysm was clipped in the hybrid operating room. DSA confirmed that the aneurysm had been clipped completely, and that the PcomA and AChA had been retained. Following surgery, the patient recovered well without any sequelae. CT angiography revealed no recurrence of the aneurysm at the 3-month follow-up. On the whole, as demonstrated by the case presented herein, when the AChA and PcomA have a common origin, the AChA and PcomA should be retained during concomitant aneurysm clipping at the ICA-PcomA to prevent severe infarction complications. Surgical clipping during hybrid surgery is a suitable choice.
The anterior choroidal artery (AChA) is one of the main arteries that needs to be retained during both craniotomy and endovascular therapy to prevent severe infarction complications (
Among all possible anomalies, the common origin of the AChA and PcomA (namely the AChA originating from the PcomA) is particularly rare (
The AChA and PcomA arising from a common stem is of utmost clinical significance, as once the PcomA is injured during the treatment of the PcomA aneurysm, infarction in the AChA region will inevitably occur.
A 58-year-old female was admitted to the First Hospital of Jilin University (Changchun, China) on October 29, 2019 after complaining of a headache with nausea and vomiting for 1 h. She had a history of diabetes for 4 years and received regular insulin injections. She denied having hypertension.
Brain computed tomography (CT) displayed a subarachnoid hemorrhage (
During craniotomy, an ICA-PcomA aneurysm was observed (
Of note, informed signed consent to participate was obtained from the patient described in the study and the patient provided consent for her data to be published.
The AChA generally originates distal to the origin of the PcomA (
However, the common origin of the PcomA and AChA is the rarest among all AChA variants (
According to the study by Padget (
A concomitant aneurysm at the ICA and PcomA junction is rare, and a rare case is reported herein. When an aneurysm occurs at the ICA-PcomA junction, this variation becomes extremely significant. An injured PcomA may induce catastrophic consequences as subsequent AChA ischemia can occur. During the treatment of PcomA aneurysms, PcomA injuries may not even lead to a poor prognosis if the circle of Willis is intact. This is due to the fact that following PcomA occlusion, blood can travel through the PCA from the reverse blood flow of the basilar artery.
However, in 20-30% of the population with fetal PCA, the basilar artery is no longer the main supplying vessel to the ipsilateral PCA (
Therefore, when the aneurysm was clipped in the hybrid operation, the AChA originating from the PcomA was clearly visualized during clipping, the aneurysm was confirmed to have been clipped completely, and the AChA of the PcomA was retained.
In conclusion, the AChA and PcomA may have a common origin in rare cases, and this anomaly may even be combined with aneurysm at the ICA-PcomA junction, which should be detected and addressed with caution, particularly in cases of fetal PcomA, and the PcomA should be retained to prevent AChA infarction. Surgical clipping in hybrid operations is controllable and thus a suitable choice.
Not applicable.
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
HC and JY designed the study and drafted the manuscript. HC collected the data. JY and HC confirm the authenticity of all the raw data. All authors have read and approved the final manuscript.
Ethics approval was not required by our institution as the present study is a case report. Informed signed consent to participate was obtained from the patient.
The patient provided consent and agreed for her data to be published.
The authors declare that they have no competing interests.
Preoperative images. (A) Brain CT scan illustrating the SAH in the suprasellar cistern and right lateral fissure cistern. (B) CTA illustrating the right PcomA aneurysm (arrow). (C) CTA illustrating the artery around the aneurysm. (D) 3-Dimensional DSA illustrating that the aneurysm is located at the junction of the ICA and PcomA and that the AChA arises from the proximal segment of the PcomA. (E and F) Left VA-DSA illustrating an absent right PCA (asterisks). AChA, anterior choroidal artery; AN, aneurysm; BA, basilar artery; CT, computed tomography; CTA, computed tomography angiography; DSA, digital subtraction angiography; ICA, internal carotid artery; L, left; MCA, middle cerebral artery; PCA, posterior cerebral artery; PcomA, posterior communicating artery; SAH, subarachnoid hemorrhage; P1, the first segment of PCA; VA, vertebral artery.
Intraoperative and post-operative follow-up images. (A) Intraoperative images showing the main arterial structures around the PcomA aneurysm. (B) First, the aneurysm was clipped using an FT853T clip, and the AChA (arrow) was visualized. (C) The aneurysm was clipped using an FT644T clip supplementally, and the PcomA and AChA were well retained. (D and E) Intraoperative DSA illustrating that the aneurysm was clipped completely and that the PcomA (triangle) and AChA (red arrow) were well retained. (F) CTA illustrating no recurrence of the aneurysm at the 3-month follow-up. ACA, anterior cerebral artery; AChA, anterior choroidal artery; AN, aneurysm; CTA, computed tomography angiography; DSA, digital subtraction angiography; ICA, internal carotid artery; MCA, middle cerebral artery; PCA, posterior cerebral artery; PcomA, posterior communicating artery.