This 37-year-old man with hypertension came to the Emergency room with complaints of sudden onset headache and right leg weakness after he stretched and yawned. Neurological examination showed alert mental state, frontal headache, and grade III weakness of the right leg. He had no remarkable past medical history, except nonspecific dizziness and headache since he was 25 years old. Head computed tomogram (CT) revealed scattered SAH at the left frontal convexities. A magnetic resonance (MR) images showed acute infarction at the rostrum of the left corpus callosum and double-lumen signal with high-signal hemorrhage (). Catheter angiogram showed multifocal dissections at the left carotid bulb and right vertebral artery with tiny aneurysm at the left proximal A2 (). His paresis seemed to be attributed to the infarction. After 3 days, dual antiplatelet agents were prescribed to prevent further ischemia and his weakness was gradually improved.\nHe underwent two more CT angiograms during the next months. Final angiogram revealed enlargement of the left A2 aneurysm and progression of focal stenosis along the ACA (). Endovascular intervention was performed under a general anesthesia by placing a 4.5×28 mm Enterprise stent (Cordis Neurovascular, Miami Lakes, FL, USA) through the A1 into the A2 segment, and deploying three Axium detachable helix coils (ev3 Inc., Irvine, CA, USA) into the aneurysm sac. Postoperative control angiogram revealed successful coil packing and flow preservation through the bilateral A2 segments (). Six months postoperatively, angiogram showed neither growth of aneurysms nor recurrence of stenosis (). He has no neurologic deficits and awaits another angiogram 12 months hereafter.
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.