Four simultaneous anterior cerebral artery aneurysms (three initially unsuspected) with surgical treatment

Distal anterior cerebral artery aneurysms are rare, comprising approximately 6% of all intracranial aneurysms. These aneurysms tend to be smaller in size, broad-based, associated with additional aneurysms and at arterial branching sites, which can make both diagnosis and treatment difficult. Here we report a case of a 63-year-old female who presented with headache and perioral paresthesia determined to be Hunt & Hess scale grade 1. Computed tomography angiography discovered a medium-sized left A2 trunk saccular aneurysm. Intraoperatively 2 additional small blister type aneurysms not noted on initial computed tomography were discovered and treated via clipping and wrapping, respectively. Postoperatively a cerebral angiogram revealed an additional small right A2 trunk broad-based aneurysm. Preoperative evaluation of cerebral vasculature with a cerebral angiogram or high-resolution digital subtraction angiography is essential as multiple aneurysms are commonly associated with anterior cerebral artery aneurysms. The patient was successfully treated without any operative or postoperative complications and has remained symptom-free at 1 year follow up.