title: Surgery of proximal anterior cerebral artery aneurysms.
abstract: BACKGROUND
  Aneurysms of the proximal segment of anterior cerebral artery (A1) are uncommon, but present a unique challenge to surgeons because of the risk of injury to the nearby perforating arteries. Surgical issues and treatment options, however, have not been detailed in the previous literature.
  
  
  METHODS
  We report a consecutive series of 11 patients with A1 aneurysms focusing on the surgical considerations. The A1 aneurysms represented 3.4% of the 322 cerebral aneurysms treated in our hospital in the last 6 years. All patients presented with subarachnoid hemorrhage, and 8 patients (73%) had multiple aneurysms.
  
  
  RESULTS
  All aneurysms were secured by neck clipping via pterional craniotomy without any surgery-related morbidity. All of the aneurysms projected superiorly or posteriorly from the origin of the perforating artery of the A1 segment. The aneurysm dome was tightly adherent to the perforating arteries in 7 cases (64%) and the base extended broadly along the axis of the parent artery in 4 cases (36%).
  
  
  CONCLUSIONS
  Separating the perforating arteries from the neck or dome of the A1 aneurysm and preserving the vessel presents a substantial challenge to the surgeon, because the aneurysm is almost always behind the parent artery in the surgical field, making it difficult to achieve good access for this particular type of dissection. Consideration should be given to additional orbitotomy, wide opening of the Sylvian fissure, mobilization of the MCA and ICA, selection of aperture clip and intra-operative shortening of the clip blades.
authors.affiliation: Department of Neurosurgery, Saiseikai Shigaken Hospital, Ohashi 2-4-1, Ritto, Shiga 520-30, Japan.
authors.forename: A
authors.initials: A
authors.lastname: Hino
authors.forename: M
authors.initials: M
authors.lastname: Fujimoto
authors.forename: Y
authors.initials: Y
authors.lastname: Iwamoto
authors.forename: H
authors.initials: H
authors.lastname: Oka
authors.forename: T
authors.initials: T
authors.lastname: Echigo
mesh_terms: D000328:Adult; D000368:Aged; D015901:Angiography, Digital Subtraction; D020771:Anterior Cerebral Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed