- Email: [email protected]
Surgical Treatment of Intracranial Anterior Ethmoidal Aneurysm: Case Report, Literature Review, and Surgical Video
Journal Pre-proof Surgical Treatment of an Intracranial Anterior Ethmoidal Aneurysm: Case Report, Literature Review and Surgical Video Thomas M. Zervos, MD, Thet Mg Mg, MD, Hesham Zakaria, MD, Kyi Hlaing, MD, Tin Htun Aung, MD, Win Myaing, MD, Jack Rock, MD PII:
S1878-8750(19)33182-1
DOI:
https://doi.org/10.1016/j.wneu.2019.12.150
Reference:
WNEU 13997
To appear in:
World Neurosurgery
Received Date: 24 October 2019 Revised Date:
23 December 2019
Accepted Date: 24 December 2019
Please cite this article as: Zervos TM, Mg TM, Zakaria H, Hlaing K, Aung TH, Myaing W, Rock J, Surgical Treatment of an Intracranial Anterior Ethmoidal Aneurysm: Case Report, Literature Review and Surgical Video, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2019.12.150. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Surgical Treatment of an Intracranial Anterior Ethmoidal Aneurysm: Case Report, Literature Review and Surgical Video
Thomas M Zervos MD 2*, Thet Mg Mg, MD1*, Hesham Zakaria, MD2 , Kyi Hlaing, MD2, Tin Htun Aung, MD1,Win Myaing, MD1, Jack Rock, MD2 1
Department of Neurosurgery, North Okkalappa General Hospital, University of Medicine, and
2
Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202
*These two authors contributed equally. Thomas Zervos, MD Department of Neurosurgery Henry Ford Hospital 2799 West Grand Blvd Detroit, MI 48202 Phone: (800) 436-7936 Fax: 313-916-7139 email: [email protected]
Key Words: Anterior ethmoidal artery aneurysm; Intracranial hemorrhage; Operative video Short Running Title: Anterior Ethmoidal Aneurysm Management
Surgical Treatment of an Intracranial Anterior Ethmoidal Aneurysm: Case Report, Literature Review and Surgical Video
ABSTRACT BACKGROUND: Anterior ethmoid aneurysms are rare with five cases of intracranial rupture and three cases of life-threatening epistaxis described in recent literature. We present a case of an intracranial ruptured anterior ethmoid aneurysm treated surgically with favorable outcome. CASE DESCRIPTION: A 64-year-old male presenting with a headache was found to have a right frontal intracranial hemorrhage with an associated 1.5 cm length x 1.8 cm maximal width anterior ethmoidal artery aneurysm. No definitive etiology of the aneurysm was identified. The aneurysm was treated utilizing a bifrontal craniotomy with interhemispheric microdissection, clip ligation and resection of the aneurysm dome for pathological analysis, which ruled out a mycotic etiology. He recovered uneventfully and returned to work with no identifiable neurological deficit. CONCLUSIONS: Consistent with prior reports, intracranial, anterior ethmoidal artery aneurysm can occur in isolation without an associated vascular malformation. Based on literature review and this case, surgical ligation is considered effective and possibly superior over endovascular treatment due to the risk of injury to the orbital vascular supply with trans-arterial treatment. Key Words: Anterior ethmoidal artery aneurysm; Intracranial hemorrhage; Operative video
1
INTRODUCTION Ruptured aneurysms of the intracranial anterior ethmoidal artery are rare. A review of the literature suggests that surgical ligation is often favored due to the risk of accessing this area through the ophthalmic artery during endovascular treatment. In previously described cases, sacrifice of the anterior ethmoidal artery along with coagulation of the aneurysm was well tolerated.1–3 Due to its anatomical course and supply to the anterior cranial fossa dura, the anterior ethmoidal artery is also important in dural arteriovenous fistulas, meningiomas, medial orbital wall decompression and epistaxis.4–6 The anterior ethmoidal artery originates from the distal ophthalmic artery within the orbit. It enters the ethmoidal foramen within the lamina papyracea and passes through the ethmoid sinus.7 It enters intracranially by passing anterior to the cribriform plate. It gives rise to the anterior falx artery, which supplies the anterior falx including the walls of the superior sagittal sinus.2,8 As such, it can also be an important supply to anterior cranial fossa meningiomas, dural arteriovenous fistulas and arteriovenous malformations in this region.9,7 Here, we describe a case of a ruptured anterior ethmoidal artery aneurysm and provide a video illustrating the surgical clip ligation of this rare entity.
CASE PRESENTATION A 64-year-old male presenting with a headache was found to have a right frontal intracranial hemorrhage (ICH) with an associated anterior ethmoidal aneurysm. Five months prior to presentation, he slipped and fell, striking his left jaw on a tree branch. He lost consciousness about 30 minutes at that time and then fully recovered. This was in his hometown, in the Western
2
part of Myanmar where no computed tomography (CT) imaging is available. He has no relevant family history, no recent infections, no fevers, and no known history of hypertension. The patient presented to North Okkalappa General Hospital Yangon General Hospital with Glascow Coma Score of 15 and a non-focal neurological examination. Computed tomography angiography (CTA) demonstrated a 1.5cm in length x 1.8cm maximal dome width aneurysm arising from the anterior ethmoidal artery (Figure 1, patient consent was given for this figure). There was an associated hematoma projecting postero-superiorly from the aneurysm. There was no erosion of the adjacent bone and no associated arterio-venous malformation (AVM) and no evidence of prior trauma on the CTA. Catheter angiography was not performed as it is not yet available in Myanmar. In order to decompress the surrounding hematoma and treat the aneurysm, a bifrontal craniotomy was performed. The patient was positioned supine in a Sugita headframe and the incision was planned (Figure 2, patient consent was given for this figure). Clip ligation and subsequent division of the anterior superior sagittal sinus allowed for an interhemispheric approach with eventual visualization of the aneurysm neck. The right frontal lobe was retracted laterally exposing the dome of the aneurysm. The feeding vessel was identified and a clip was placed over the neck of the aneurysm with preservation of the parent vessel (Operative Video, patient consent was given for this video). After clip ligation, the aneurysm dome was excised and sent for histopathology which revealed aneurysmal dilation of fibrovascular arterial wall lined by endothelial cells. No discernible atheromatous plaques, calcifications, epithelioid granulomas or suggestion of a mycotic component (Figure 3) were found. He was neurologically unchanged postoperatively
3
and discharged in good condition (Figure 4, patient consent was given for this figure). At followup he was at his previous functional baseline (Figure 4). DISCUSSION To the best of our knowledge, only five reports of intracranial anterior ethmoidal artery aneurysm have been described (Table 1), and of these five cases, the etiology was found to be secondary to aberrancies of the normal intracranial flow in four. In two cases, the etiology was thought to be secondary to carotid occlusion resulting in increased collateral flow through the ethmoid via external carotid to the ophthalmic anastomosis.1,3 Another case was associated with an olfactory groove meningioma supplied by the anterior ethmoidal artery.9 In yet another, there was an anastomotic connection between the anterior ethmoidal artery and the fronto-orbital artery, with the parent vessel actually being the fronto-orbital artery.10 The last case had no identifiable etiology.2 Due to the risk of endovascular access via the ophthalmic artery, all cases were treated surgically with favorable outcomes. Three cases of ruptured extracranial anterior ethmoidal artery aneurysms presenting with life-threatening epistaxis have been described.5,11,12 In one report, uncontrollable epistaxis occurred several weeks after endonasal resection of a large, recurrent, chondrosarcoma. A pseudoaneurysm was identified arising from the medial orbital segment of the anterior ethmoidal artery and treated with open surgical ligation.11 In another report, delayed epistaxis occurred after transphenoidal surgery from an anterior ethmoidal artery pseudoaneurysm and was treated endovascularly.12 In the last case, epistaxis from a traumatic anterior ethmoidal artery aneurysm occurred after facial trauma and was embolized.5 Conventional approaches to lesions of the cribriform plate include unilateral or bifrontal, pterional or extended frontal craniotomy and endovascular when appropriate.4 The subfrontal
4
approach is appropriate when proximal control can be accessed above the cribriform plate. Conversely, in the pterional approach, early proximal control is not possible. In the treatment of complex lesions such as cribriform plate meningiomas, a craniotomy facilitating extradural access to the ethmoidal arteries in the medial orbital wall has been described, however this would likely increase the risk of cerebrospinal fluid leaks, wound infections and injury to lacrimal ducts.4 While endovascular treatment of lesions of the anterior ethmoidal artery have been described surgical management is felt to be superior due to the lower complication rate and higher curative potential.13,14
CONCLUSION This case report describes the successful surgical treatment of an intracranial anterior ethmoid aneurysm. Consistent with prior cases, surgical ligation over endovascular treatment provided a curative treatment option without significant side effects. Acknowledgements: The authors would like to thank Susan MacPhee for her editorial assistance.
5
REFERENCES 1. Tasker RR. Ruptured berry aneurysm of the anterior ethmoidal artery associated with bilateral spontaneous internal carotid artery occlusion in the neck. J Neurosurg. 1983;59(4):687691. doi:10.3171/jns.1983.59.4.0687 2. Ranjan A, Joseph T. Giant aneurysm of anterior ethmoidal artery presenting with intracranial hemorrhage. J Neurosurg. 1994;81(6):934-936. doi:10.3171/jns.1994.81.6.0934 3. Costa LB da, Valiante T, TerBrugge K, Tymianski M. Anterior Ethmoidal Artery Aneurysm and Intracerebral Hemorrhage. Am J Neuroradiol. 2006;27(8):1672-1674. 4. McDermott MW, Rootman J, Durity FA. Subperiosteal, subperiorbital dissection and division of the anterior and posterior ethmoid arteries for meningiomas of the cribriform plate and planum sphenoidale: technical note. Neurosurgery. 1995;36(6):1215-1218; discussion 12181219. doi:10.1227/00006123-199506000-00027 5. Kuranari Y, Akiyama T, Yanagisawa K, et al. Traumatic Anterior Ethmoidal Artery Pseudoaneurysm with Repeated Epistaxis Treated by Transarterial Embolization: A Case Report. J Neuroendovascular Ther. 2019;13(2):72-76. doi:10.5797/jnet.cr.2018-0075 6. Chen Z, Tang W, Liu Z, Li F, Feng H, Zhu G. A Dural Arteriovenous Fistula of the Anterior Cranial Fossa Angiographically Mimicking an Anterior Ethmoidal Artery Aneurysm. J Neuroimaging. 2010;20(4):382-385. doi:10.1111/j.1552-6569.2009.00392.x 7. White DV, Sincoff EH, Abdulrauf SI. Anterior Ethmoidal Artery: Microsurgical Anatomy and Technical Considerations: Oper Neurosurg. 2005;56:406-410. doi:10.1227/01.NEU.0000156550.83880.D0 8. Rhoton AL. The orbit. Neurosurgery. 2002;51(4 Suppl):S303-334.
6
9. Tachikawa T, Adachi J, Nishikawa R, Matsutani M. An anterior ethmoidal artery aneurysm associated with an olfactory groove meningioma. J Neurosurg. 2002;97(6):1479. doi:10.3171/jns.2002.97.6.1479 10. Enomoto H, Goto H, Murase M. Subarachnoid hemorrhage due to a cerebral aneurysm at the anastomotic site between the frontoorbital artery and the anterior ethmoidal artery: a case report. Neurosurgery. 1985;17(2):335-337. doi:10.1227/00006123-198508000-00018 11. Patel A, Gandhi D, Taylor R, Woodworth G. Use of Dyna CT in evaluation and treatment of pseudoaneurysm secondary to craniofacial tumor resection: Case report and diagnostic implications. Surg Neurol Int. 2014;5(1):48. doi:10.4103/2152-7806.130561 12. De Los Reyes KM, Gross BA, Frerichs KU, et al. Incidence, risk factors and management of severe post-transsphenoidal epistaxis. J Clin Neurosci Off J Neurosurg Soc Australas. 2015;22(1):116-122. doi:10.1016/j.jocn.2014.07.004 13. Lefkowitz M, Giannotta SL, Hieshima G, et al. Embolization of neurosurgical lesions involving the ophthalmic artery. Neurosurgery. 1998;43(6):1298-1303. doi:10.1097/00006123199812000-00016 14. Lawton MT, Chun J, Wilson CB, Halbach VV. Ethmoidal dural arteriovenous fistulae: an assessment of surgical and endovascular management. Neurosurgery. 1999;45(4):805-810; discussion 810-811. doi:10.1097/00006123-199910000-00014
7
FIGURE CAPTIONS Figure 1: Aneurysmal anatomical relationships. Axial, coronal and sagittal computed tomography angiography (CTA) images illustrate the relationship of the aneurysm with the skull base and surrounding hematoma. Oblique three-dimensional CTA reconstructed images provide a sense of the aneurysmal morphology and relationship to parent vessels. Figure 2: Surgical Positioning. The patient was positioned supine in a Sugita headframe and a bifrontal incision was planned. Figure 3: Aneurysmal dome histopathology. Pathological evaluation revealed a saccular aneurysm with partial thrombosis. There was no evidence of vasculitis, or atheromatous or infectious changes. A. Hematoxylin and eosin staining shows aneurysmal wall thinning, but is otherwise unremarkable. B-D When the specimen is examined at higher magnification, an organized thrombus is appreciated in the lumen. Figure 4: Clinical outcome. A. On postoperative examination, the patient was alert and awake with no discernible neurological deficits. B. On follow-up, the patient’s incision was well healed and he was able to return to work.
8
Table 1: Summary of the reports of intracranial anterior ethmoid artery aneurysm described in peer-reviewed literature from 1980-2019. (Table is based on a Pubmed query using the search term, “anterior ethmoidal artery aneurysm.”)
New Year
Etiology
Treatment
ICH/SAH
Citation
no
yes
1
no
yes
10
no
yes
2
no
no
2
no
yes
3
Deficit?
bilateral carotid occlusion
right frontal craniotomy with
resulting in extracranial to
electrocautery obliteration of the
ophthalmic collateral and
aneurysm and parent vessel due
augmented ethmoidal artery flow
to adherence to the dura
1983
frontotemporoparietal anastomosis between the frontocraniotomy with ligation of the 1985
orbital artery and anterior aneurysm neck, preserving the ethmoidal artery parent vessels left frontal craniotomy for evacuation of frontopolar and
1994
unidentified
subdural hematoma, coagulation of the aneurysm and parent vessel
olfactory groove meningioma fed
aneurysmal involution after
by the anterior ethmoidal artery.
meningioma resection
2002
right carotid artery occlusion with right frontotemporal craniotomy collateralization and increased 2006
with aneurysm and parent vessel flow through the anterior coagulation at the skull base ethmoidal artery 1
All citations from articles found using this query were also reviewed for inclusion based on referenced content and title. Descriptions of the three known reports of extracranial ethmoidal artery pseudoaneurysms are provided separately in the discussion.
2
Abbreviations: Arterio-venous malformation (AVM) Computed tomography (CT) Computed tomography angiography (CTA) Intracranial hemorrhage (ICH)
Disclosure/Conflict of Interest Statement:
Thomas M. Zervos Thet Mg Mg Hesham Zakaria Kyi Hlaing Tin Htun Aung Win Myaing Jack Rock The above authors hereby state that there are no disclosures or conflicts of interest to report.
S1878-8750(19)33182-1
DOI:
https://doi.org/10.1016/j.wneu.2019.12.150
Reference:
WNEU 13997
To appear in:
World Neurosurgery
Received Date: 24 October 2019 Revised Date:
23 December 2019
Accepted Date: 24 December 2019
Please cite this article as: Zervos TM, Mg TM, Zakaria H, Hlaing K, Aung TH, Myaing W, Rock J, Surgical Treatment of an Intracranial Anterior Ethmoidal Aneurysm: Case Report, Literature Review and Surgical Video, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2019.12.150. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Surgical Treatment of an Intracranial Anterior Ethmoidal Aneurysm: Case Report, Literature Review and Surgical Video
Thomas M Zervos MD 2*, Thet Mg Mg, MD1*, Hesham Zakaria, MD2 , Kyi Hlaing, MD2, Tin Htun Aung, MD1,Win Myaing, MD1, Jack Rock, MD2 1
Department of Neurosurgery, North Okkalappa General Hospital, University of Medicine, and
2
Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202
*These two authors contributed equally. Thomas Zervos, MD Department of Neurosurgery Henry Ford Hospital 2799 West Grand Blvd Detroit, MI 48202 Phone: (800) 436-7936 Fax: 313-916-7139 email: [email protected]
Key Words: Anterior ethmoidal artery aneurysm; Intracranial hemorrhage; Operative video Short Running Title: Anterior Ethmoidal Aneurysm Management
Surgical Treatment of an Intracranial Anterior Ethmoidal Aneurysm: Case Report, Literature Review and Surgical Video
ABSTRACT BACKGROUND: Anterior ethmoid aneurysms are rare with five cases of intracranial rupture and three cases of life-threatening epistaxis described in recent literature. We present a case of an intracranial ruptured anterior ethmoid aneurysm treated surgically with favorable outcome. CASE DESCRIPTION: A 64-year-old male presenting with a headache was found to have a right frontal intracranial hemorrhage with an associated 1.5 cm length x 1.8 cm maximal width anterior ethmoidal artery aneurysm. No definitive etiology of the aneurysm was identified. The aneurysm was treated utilizing a bifrontal craniotomy with interhemispheric microdissection, clip ligation and resection of the aneurysm dome for pathological analysis, which ruled out a mycotic etiology. He recovered uneventfully and returned to work with no identifiable neurological deficit. CONCLUSIONS: Consistent with prior reports, intracranial, anterior ethmoidal artery aneurysm can occur in isolation without an associated vascular malformation. Based on literature review and this case, surgical ligation is considered effective and possibly superior over endovascular treatment due to the risk of injury to the orbital vascular supply with trans-arterial treatment. Key Words: Anterior ethmoidal artery aneurysm; Intracranial hemorrhage; Operative video
1
INTRODUCTION Ruptured aneurysms of the intracranial anterior ethmoidal artery are rare. A review of the literature suggests that surgical ligation is often favored due to the risk of accessing this area through the ophthalmic artery during endovascular treatment. In previously described cases, sacrifice of the anterior ethmoidal artery along with coagulation of the aneurysm was well tolerated.1–3 Due to its anatomical course and supply to the anterior cranial fossa dura, the anterior ethmoidal artery is also important in dural arteriovenous fistulas, meningiomas, medial orbital wall decompression and epistaxis.4–6 The anterior ethmoidal artery originates from the distal ophthalmic artery within the orbit. It enters the ethmoidal foramen within the lamina papyracea and passes through the ethmoid sinus.7 It enters intracranially by passing anterior to the cribriform plate. It gives rise to the anterior falx artery, which supplies the anterior falx including the walls of the superior sagittal sinus.2,8 As such, it can also be an important supply to anterior cranial fossa meningiomas, dural arteriovenous fistulas and arteriovenous malformations in this region.9,7 Here, we describe a case of a ruptured anterior ethmoidal artery aneurysm and provide a video illustrating the surgical clip ligation of this rare entity.
CASE PRESENTATION A 64-year-old male presenting with a headache was found to have a right frontal intracranial hemorrhage (ICH) with an associated anterior ethmoidal aneurysm. Five months prior to presentation, he slipped and fell, striking his left jaw on a tree branch. He lost consciousness about 30 minutes at that time and then fully recovered. This was in his hometown, in the Western
2
part of Myanmar where no computed tomography (CT) imaging is available. He has no relevant family history, no recent infections, no fevers, and no known history of hypertension. The patient presented to North Okkalappa General Hospital Yangon General Hospital with Glascow Coma Score of 15 and a non-focal neurological examination. Computed tomography angiography (CTA) demonstrated a 1.5cm in length x 1.8cm maximal dome width aneurysm arising from the anterior ethmoidal artery (Figure 1, patient consent was given for this figure). There was an associated hematoma projecting postero-superiorly from the aneurysm. There was no erosion of the adjacent bone and no associated arterio-venous malformation (AVM) and no evidence of prior trauma on the CTA. Catheter angiography was not performed as it is not yet available in Myanmar. In order to decompress the surrounding hematoma and treat the aneurysm, a bifrontal craniotomy was performed. The patient was positioned supine in a Sugita headframe and the incision was planned (Figure 2, patient consent was given for this figure). Clip ligation and subsequent division of the anterior superior sagittal sinus allowed for an interhemispheric approach with eventual visualization of the aneurysm neck. The right frontal lobe was retracted laterally exposing the dome of the aneurysm. The feeding vessel was identified and a clip was placed over the neck of the aneurysm with preservation of the parent vessel (Operative Video, patient consent was given for this video). After clip ligation, the aneurysm dome was excised and sent for histopathology which revealed aneurysmal dilation of fibrovascular arterial wall lined by endothelial cells. No discernible atheromatous plaques, calcifications, epithelioid granulomas or suggestion of a mycotic component (Figure 3) were found. He was neurologically unchanged postoperatively
3
and discharged in good condition (Figure 4, patient consent was given for this figure). At followup he was at his previous functional baseline (Figure 4). DISCUSSION To the best of our knowledge, only five reports of intracranial anterior ethmoidal artery aneurysm have been described (Table 1), and of these five cases, the etiology was found to be secondary to aberrancies of the normal intracranial flow in four. In two cases, the etiology was thought to be secondary to carotid occlusion resulting in increased collateral flow through the ethmoid via external carotid to the ophthalmic anastomosis.1,3 Another case was associated with an olfactory groove meningioma supplied by the anterior ethmoidal artery.9 In yet another, there was an anastomotic connection between the anterior ethmoidal artery and the fronto-orbital artery, with the parent vessel actually being the fronto-orbital artery.10 The last case had no identifiable etiology.2 Due to the risk of endovascular access via the ophthalmic artery, all cases were treated surgically with favorable outcomes. Three cases of ruptured extracranial anterior ethmoidal artery aneurysms presenting with life-threatening epistaxis have been described.5,11,12 In one report, uncontrollable epistaxis occurred several weeks after endonasal resection of a large, recurrent, chondrosarcoma. A pseudoaneurysm was identified arising from the medial orbital segment of the anterior ethmoidal artery and treated with open surgical ligation.11 In another report, delayed epistaxis occurred after transphenoidal surgery from an anterior ethmoidal artery pseudoaneurysm and was treated endovascularly.12 In the last case, epistaxis from a traumatic anterior ethmoidal artery aneurysm occurred after facial trauma and was embolized.5 Conventional approaches to lesions of the cribriform plate include unilateral or bifrontal, pterional or extended frontal craniotomy and endovascular when appropriate.4 The subfrontal
4
approach is appropriate when proximal control can be accessed above the cribriform plate. Conversely, in the pterional approach, early proximal control is not possible. In the treatment of complex lesions such as cribriform plate meningiomas, a craniotomy facilitating extradural access to the ethmoidal arteries in the medial orbital wall has been described, however this would likely increase the risk of cerebrospinal fluid leaks, wound infections and injury to lacrimal ducts.4 While endovascular treatment of lesions of the anterior ethmoidal artery have been described surgical management is felt to be superior due to the lower complication rate and higher curative potential.13,14
CONCLUSION This case report describes the successful surgical treatment of an intracranial anterior ethmoid aneurysm. Consistent with prior cases, surgical ligation over endovascular treatment provided a curative treatment option without significant side effects. Acknowledgements: The authors would like to thank Susan MacPhee for her editorial assistance.
5
REFERENCES 1. Tasker RR. Ruptured berry aneurysm of the anterior ethmoidal artery associated with bilateral spontaneous internal carotid artery occlusion in the neck. J Neurosurg. 1983;59(4):687691. doi:10.3171/jns.1983.59.4.0687 2. Ranjan A, Joseph T. Giant aneurysm of anterior ethmoidal artery presenting with intracranial hemorrhage. J Neurosurg. 1994;81(6):934-936. doi:10.3171/jns.1994.81.6.0934 3. Costa LB da, Valiante T, TerBrugge K, Tymianski M. Anterior Ethmoidal Artery Aneurysm and Intracerebral Hemorrhage. Am J Neuroradiol. 2006;27(8):1672-1674. 4. McDermott MW, Rootman J, Durity FA. Subperiosteal, subperiorbital dissection and division of the anterior and posterior ethmoid arteries for meningiomas of the cribriform plate and planum sphenoidale: technical note. Neurosurgery. 1995;36(6):1215-1218; discussion 12181219. doi:10.1227/00006123-199506000-00027 5. Kuranari Y, Akiyama T, Yanagisawa K, et al. Traumatic Anterior Ethmoidal Artery Pseudoaneurysm with Repeated Epistaxis Treated by Transarterial Embolization: A Case Report. J Neuroendovascular Ther. 2019;13(2):72-76. doi:10.5797/jnet.cr.2018-0075 6. Chen Z, Tang W, Liu Z, Li F, Feng H, Zhu G. A Dural Arteriovenous Fistula of the Anterior Cranial Fossa Angiographically Mimicking an Anterior Ethmoidal Artery Aneurysm. J Neuroimaging. 2010;20(4):382-385. doi:10.1111/j.1552-6569.2009.00392.x 7. White DV, Sincoff EH, Abdulrauf SI. Anterior Ethmoidal Artery: Microsurgical Anatomy and Technical Considerations: Oper Neurosurg. 2005;56:406-410. doi:10.1227/01.NEU.0000156550.83880.D0 8. Rhoton AL. The orbit. Neurosurgery. 2002;51(4 Suppl):S303-334.
6
9. Tachikawa T, Adachi J, Nishikawa R, Matsutani M. An anterior ethmoidal artery aneurysm associated with an olfactory groove meningioma. J Neurosurg. 2002;97(6):1479. doi:10.3171/jns.2002.97.6.1479 10. Enomoto H, Goto H, Murase M. Subarachnoid hemorrhage due to a cerebral aneurysm at the anastomotic site between the frontoorbital artery and the anterior ethmoidal artery: a case report. Neurosurgery. 1985;17(2):335-337. doi:10.1227/00006123-198508000-00018 11. Patel A, Gandhi D, Taylor R, Woodworth G. Use of Dyna CT in evaluation and treatment of pseudoaneurysm secondary to craniofacial tumor resection: Case report and diagnostic implications. Surg Neurol Int. 2014;5(1):48. doi:10.4103/2152-7806.130561 12. De Los Reyes KM, Gross BA, Frerichs KU, et al. Incidence, risk factors and management of severe post-transsphenoidal epistaxis. J Clin Neurosci Off J Neurosurg Soc Australas. 2015;22(1):116-122. doi:10.1016/j.jocn.2014.07.004 13. Lefkowitz M, Giannotta SL, Hieshima G, et al. Embolization of neurosurgical lesions involving the ophthalmic artery. Neurosurgery. 1998;43(6):1298-1303. doi:10.1097/00006123199812000-00016 14. Lawton MT, Chun J, Wilson CB, Halbach VV. Ethmoidal dural arteriovenous fistulae: an assessment of surgical and endovascular management. Neurosurgery. 1999;45(4):805-810; discussion 810-811. doi:10.1097/00006123-199910000-00014
7
FIGURE CAPTIONS Figure 1: Aneurysmal anatomical relationships. Axial, coronal and sagittal computed tomography angiography (CTA) images illustrate the relationship of the aneurysm with the skull base and surrounding hematoma. Oblique three-dimensional CTA reconstructed images provide a sense of the aneurysmal morphology and relationship to parent vessels. Figure 2: Surgical Positioning. The patient was positioned supine in a Sugita headframe and a bifrontal incision was planned. Figure 3: Aneurysmal dome histopathology. Pathological evaluation revealed a saccular aneurysm with partial thrombosis. There was no evidence of vasculitis, or atheromatous or infectious changes. A. Hematoxylin and eosin staining shows aneurysmal wall thinning, but is otherwise unremarkable. B-D When the specimen is examined at higher magnification, an organized thrombus is appreciated in the lumen. Figure 4: Clinical outcome. A. On postoperative examination, the patient was alert and awake with no discernible neurological deficits. B. On follow-up, the patient’s incision was well healed and he was able to return to work.
8
Table 1: Summary of the reports of intracranial anterior ethmoid artery aneurysm described in peer-reviewed literature from 1980-2019. (Table is based on a Pubmed query using the search term, “anterior ethmoidal artery aneurysm.”)
New Year
Etiology
Treatment
ICH/SAH
Citation
no
yes
1
no
yes
10
no
yes
2
no
no
2
no
yes
3
Deficit?
bilateral carotid occlusion
right frontal craniotomy with
resulting in extracranial to
electrocautery obliteration of the
ophthalmic collateral and
aneurysm and parent vessel due
augmented ethmoidal artery flow
to adherence to the dura
1983
frontotemporoparietal anastomosis between the frontocraniotomy with ligation of the 1985
orbital artery and anterior aneurysm neck, preserving the ethmoidal artery parent vessels left frontal craniotomy for evacuation of frontopolar and
1994
unidentified
subdural hematoma, coagulation of the aneurysm and parent vessel
olfactory groove meningioma fed
aneurysmal involution after
by the anterior ethmoidal artery.
meningioma resection
2002
right carotid artery occlusion with right frontotemporal craniotomy collateralization and increased 2006
with aneurysm and parent vessel flow through the anterior coagulation at the skull base ethmoidal artery 1
All citations from articles found using this query were also reviewed for inclusion based on referenced content and title. Descriptions of the three known reports of extracranial ethmoidal artery pseudoaneurysms are provided separately in the discussion.
2
Abbreviations: Arterio-venous malformation (AVM) Computed tomography (CT) Computed tomography angiography (CTA) Intracranial hemorrhage (ICH)
Disclosure/Conflict of Interest Statement:
Thomas M. Zervos Thet Mg Mg Hesham Zakaria Kyi Hlaing Tin Htun Aung Win Myaing Jack Rock The above authors hereby state that there are no disclosures or conflicts of interest to report.