A 56-year-old male presented with deep stuporous consciousness with a Hunt and Hess grade of IV. Initial brain CT showed a thick SAH at the basal cistern, sylvian fissures, and anterior interhemispheric fissure (). Conventional cerebral angiography showed an azygous ACA, chronic total occlusion of the left proximal internal carotid artery (ICA), and a fusiform aneurysm on the right side wall of the A2 segment (). An arterial fenestration was also observed at the cavernous ICA. The aneurysm measured 6.25×2.86 mm in size on the 3-dimensional rotational angiogram with a neck size of 6.25 mm and height of 2.02 mm. The distal ACA flow remained patent without stenosis or occlusion.\nStent-assisted coil embolization of the azygous A2 dissecting aneurysm was performed under general anesthesia. A tiny remnant was left at the proximal portion (), however, follow-up angiography after two weeks showed complete obliteration of the aneurysm with preservation of the parent artery (). He showed improvement to drowsy mentality, but remained in a wheelchair-bound state.
Patient, 45-years-old female, was admitted in hospital on the next day after intracranial hemorrhage.\nIt is known that the onset of the disease was with a sudden headache, pain in cervico-occipital localization and rise of the arterial blood pressure up to 220 mm Hg. On admission to hospital a condition was critical, 11 Glasgow Coma Scale, Hunt-Hess 3 meningeal signs. The pupils are equal. Oculomotor dysfunction and visible paresis are not detected. The Babinsky signs on both sides.\nData on the previous infections, craniocerebral injuries and systemic connective tissue disorders are not detected.\nTranscranial Doppler verified the rise of cerebral blood flow up to 220 cm/s.\nBrain computed tomography (CT) scan and CT-angiography revealed the right sided FA on the A1-segment of ACA, basal SAH, intracerebral hematoma in the mediobasal frontal lobe and in the interhemispheric fissure []. Cerebral angiography performing was associated with a high risk of rebleeding and patient’s condition worsening.\nBecause of a critical condition of the patient, we decided to treat the patient conservatively. The main protocol includes treatment of cerebral vasospasm and intracranial hypertension. This choice was explained by the possible need for trapping the A1-segment with revascularization, which could lead to worsen of the patient’s condition and an unfavorable outcome.\nAfter 12 days, when the patient condition was stabilized we performed a right-sided lateral supraorbital craniotomy, microsurgical clipping of the eccentrically FA on the A1 segment of ACA.\nTraditional microneurosurgical technique was used. The aneurysmal dilatation occupied the distal part of the A1 segment. Along with fibrin masses in the area of the rupture the eccentrically fusiformed part of the aneurysm was visualized which was adhered to the optic nerve. In this case, the posterior wall of the artery was not changed. Aneurysm was dissected and clipped. There were no intraoperative complications.\nThe patient was extubated in the operating room and transferred to the intensive care unit. The postoperative period was uneventful. On the CT scan there are no postoperative complications.\nIntraoperative photo and the CT scans of the brain in [].\nThe patient was discharged without neurological deficit on the day 9th day after surgery.