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Anterior cerebral artery syndrome — Clinical Guidelines

Overview

Anterior cerebral artery (ACA) syndrome encompasses neurological deficits resulting from occlusions or aneurysms affecting the ACA, often leading to specific impairments in motor function, cognition, and behavior, particularly involving the frontal and parietal lobes. 7

Diagnosis

Clinical Presentation: Symptoms include motor deficits, cognitive impairments, and personality changes. 7

Imaging Studies:

- CT/CTA: Initial imaging to detect aneurysms or infarcts. 1 6 - MRI/MRA: Detailed visualization of vascular anatomy and infarcted areas. 6

Angiography: Essential for definitive diagnosis, distinguishing benign dilatations (e.g., azygos ACA shield) from aneurysms. 1 5

Transcranial Doppler: Useful for assessing blood flow velocities in ACA complex arteries. 5

Management

Surgical Approaches:

- Interhemispheric Approach: Effective for distal ACA aneurysms, with modifications like anterior callosotomy for better exposure. 8 - Endovascular Techniques: Use of flow diverters (e.g., Pipeline) for complex aneurysms. 3

Specific Techniques:

- Clip-wrapping: For fusiform aneurysms. 4 - Bypass Surgery: Including frontopolar-to-A2 bypass for complex cases. 4

Resection: Indicated for dissecting aneurysms that grow or cause significant symptoms. 6

Special Populations

Elderly: Thorough anatomical investigation via DSA is crucial to differentiate benign dilatations from aneurysms. 1

Comorbidities: Management strategies may need adjustment based on patient-specific conditions, often requiring combined endovascular and surgical techniques. 4

Key Recommendations

Thorough Angiographic Evaluation: Essential for accurate diagnosis, distinguishing benign dilatations from aneurysms to avoid unnecessary interventions. (Evidence: Moderate 1 5)

Consider Interhemispheric Approach with Modifications: For distal ACA aneurysms, anterior callosotomy can enhance surgical exposure and outcomes. (Evidence: Weak 8)

Use of Flow Diverters for Complex Aneurysms: Effective in treating complex ACA aneurysms with mid-term success, though off-label use should be carefully considered. (Evidence: Moderate 3)

Surgical Resection for Progressive Dissecting Aneurysms: Indicated in cases where aneurysms grow or cause significant neurological deficits, despite conservative management being common. (Evidence: Weak 6)

References

1 Andreev A, Vranic JE, Doron O, Regenhardt RW, Patel AB. Azygos anterior cerebral artery shield masquerading as an aneurysm. The neuroradiology journal 2024. link 2 Imada Y, Mihara C. A Simple Method to Estimate the Trajectory to the Genu of the Corpus Callosum in the Interhemispheric Approach for Distal Anterior Cerebral Artery Aneurysms. Neurologia medico-chirurgica 2022. link 3 Dabus G, Grossberg JA, Cawley CM, Dion JE, Puri AS, Wakhloo AK et al.. Treatment of complex anterior cerebral artery aneurysms with Pipeline flow diversion: mid-term results. Journal of neurointerventional surgery 2017. link 4 Chen PR, Abla AA, McDougall CG, Spetzler RF, Albuquerque FC. Surgical techniques for unclippable fusiform A2-anterior cerebral artery aneurysms and description of a frontopolar-to-A2 bypass. World neurosurgery 2014. link 5 Kaspera W, Ładziński P, Słowiński J, Kopera M, Tomalski W, Slaska-Kaspera A. Blood flow velocity in the arteries of the anterior cerebral artery complex in patients with an azygos anterior cerebral artery aneurysm: a transcranial color-coded sonography study. Clinical neurology and neurosurgery 2009. link 6 Wakabayashi Y, Nakano T, Isono M, Shimomura T, Hori S. Dissecting aneurysm of the anterior cerebral artery requiring surgical treatment--case report. Neurologia medico-chirurgica 2000. link 7 Beeckmans K, Vancoillie P, Michiels K. Neuropsychological deficits in patients with an anterior communicating artery syndrome: a multiple case study. Acta neurologica Belgica 1998. link 8 Traynelis VC, Dunker RO. Interhemispheric approach with callosal resection for distal anterior cerebral artery aneurysms. Technical note. Journal of neurosurgery 1992. link 9 Mäurer J, Mäurer E, Perneczky A. Surgically verified variations in the A1 segment of the anterior cerebral artery. Report of two cases. Journal of neurosurgery 1991. link

Anterior cerebral artery syndrome