Endovascular treatment of dissecting distal anterior cerebral artery pseudo-aneurysms: insights from a six-patient case series.

BACKGROUND

Dissecting pseudoaneurysms of the distal anterior cerebral artery (dACA) are extremely rare but highly prone to rupture. Evidence to guide endovascular management remains limited to isolated reports.

OBJECTIVES

To describe the clinical presentation, angiographic features, treatment selection, and outcomes of a consecutive dACA dissecting pseudo-aneurysm series.

METHODS

We retrospectively reviewed a prospectively maintained cerebrovascular database (January 2013 – May 2025) at a single tertiary center. Adults with angiographically verified dissecting pseudoaneurysms in ACA segments A2–A5 who were treated endovascularly were included. We abstracted demographics, risk factors, aneurysm morphology, and procedural details. Strategies were categorized as reconstructive (stent-assisted coiling, flow diversion) or deconstructive (parent-artery sacrifice using coils and/or liquid embolic agents). The primary outcome was the modified Rankin Scale (mRS) at discharge (favorable = 0–2). Secondary analyses examined anatomical or technical predictors of outcome.

RESULTS

Six patients qualified based on the criteria (average age 52.8 ± 13.1 years; 3 were female). Prevalent issues included hypertension (83%), hyperlipidemia (33%), and active or former smoking (33%); three cases (50%) exhibited rupture. Treatment strategies included deconstructive parent-artery sacrifice in 3 patients (50%) using coils and/or liquid embolic agents, and reconstructive techniques in 3 patients (50%), consisting of flow diversion in 2 patients (33%) and stent-assisted coiling in 1 patient (17%). Three lesions treated with endovascular coil embolization achieved complete immediate angiographic exclusion. There were no in-hospital fatalities. Four patients (67%) were discharged with a favorable mRS, and 4 out of 6 patients with available follow-up data (67%) maintained independence at an average of 34.8 ± 17.2 months.

CONCLUSIONS

Based on our case series, endovascular management of dissecting dACA pseudo-aneurysms is feasible and results in good functional recovery. Given the typical proximal intimal tear, friable vessel walls, and robust hemispheric collaterals, sacrificing the proximal parent artery was associated with durable angiographic exclusion in this small series. These observations are descriptive and hypothesis-generating, and treatment decisions should be individualized based on anatomy and collateral circulation.