Letters to the Editor 3.

Yang SH, Lee KS, Lee KY, Lee SW, Hong YK. Pituitary apoplexy producing internal carotid artery compression: A case report. J Korean Med Sci 2008;23:1113‑7. 4. Bernstein M, Hegele RA, Gentili F, Brothers M, Holgate R, Sturtridge WC, et al. Pituitary apoplexy associated with a triple bolus test. Case report. J Neurosurg 1984;61:586‑90. 5. Kurschel S, Leber KA, Scarpatetti M, Roll P. Rare fatal vascular complication of transsphenoidal surgery. Acta Neurochir (Wien) 2005;147:321‑5. 6. Goel A, Deogaonkar M, Desai K. Fatal postoperative ‘pituitary apoplexy’: Its cause and management. Br J Neurosurg 1995;9:37‑40. 7. Ahmad FU, Pandey P, Mahapatra AK. Post operative’pituitary apoplexy’ in giant pituitary adenomas: A series of cases. Neurol India 2005;53:326‑8. Access this article online Quick Response Code:

Figure 9: Artist’s impression of encasement of ICA by tumor before surgery

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DOI: 10.4103/0976-3147.140016

Partially thrombosed distal orbitofrontal artery aneurysm mimicking an A1 segment aneurysm Figure 10: Artist’s impression of strangulation of ICA by residual tumor after the surgery

A  pre‑op MRI finding of encasement of ICA should alert the neurosurgeon to this rare complication. Kannepalli Venkata Laxmi Narasinga Rao, Jagath Lal Gangadharan, Vikas Vazhayil, Sampath Somanna Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India Address for correspondence: Dr. Narasinga Rao K.V.L, Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India. E‑mail: [email protected]

References 1.

Hardy J. Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 1969;16:185‑217. 2. Zervas NT. Surgical results for pituitary adenomas: Results of an international survey. In: Black P, Zervas NT, Ridgeway E, editors. Secretory Tumors of the Pituitary Gland. Progress in Endocrine Research and Therapy 1. New York: Raven Press; 1984. p. 377‑85. 436

Sir, Distal orbitofrontal arteries (OFAs) are very rare.[1] The location of these aneurysms can be identified with digital subtraction angiography. However, when it is partially thrombosed the filling portion of the aneurysm may partially overlap on a larger vessel wrongly implicating the vessel as the site of origin. A  63‑year‑old lady presented with history of sudden onset severe headache. She was not a hypertensive and had no significant past medical or surgical history. CT scan revealed blood in the anterior interhemispheric fissure. Digital subtraction angiography (DSA) revealed a small aneurysm apparently arising from the left A1 segment, proximal to the AcomA region. The aneurysm was seen only in oblique views [Figure 1a and b]. There were no branching vessels at the origin. She underwent a left pterional craniotomy and exploration. At surgery there was no aneurysm along the A1 segment, however buried in the gyrus rectus was a partially thrombosed aneurysm [Figure 2a and b]. On further dissection the left OFA origin on A2 was identified. It was dissected distally and was found to enter into the aneurysm. The distal portion of the OFA emerged from the aneurysm. The recurrent artery of Heubner (RAH) which arose just distal to the anterior communicating

Journal of Neurosciences in Rural Practice | October - December 2014 | Vol 5 | Issue 4

Letters to the Editor

We report a rare case of partially thrombosed OFA aneurysm arising distal to the origin of the vessel in a patient who had no predisposing factors. Such a case has not been described before. Partially thrombosed aneurysms may give a misleading picture of its origin. It is important to distinguish the OFA from RAH prior to sacrifice of the vessel. a

Dhananjaya Ishwar Bhat, Dhaval P Shukla, Bhagavatula Indira Devi

b

Figure 1: Digital subtraction angiography left internal carotid artery injection. (a) AP view: No definite aneurysm except for a double density shadow in distal A1 (arrow). (b) Oblique view which shows an aneurysm arising from the distal A1 (arrow)

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India Address for correspondence: Dr. Dhananjaya Ishwar Bhat, Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore ‑ 560 029, Karnataka, India. E‑mail: [email protected]

References 1. a

b

Figure 2: (a) Intraoperative picture. (b) Magnified view: Showing a partially thrombosed aneurysm arising from the orbitofrontal artery distal to its origin. DOF = Distal orbitofrontal artery, POF = Proximal orbitofrontal artery, RAH = Recurrent artery of Heubner, Rt = Right, Lt = Left

artery (Acom) junction was identified separately from the aneurysm. Excision of the aneurysm along with the vessel was done. Post operatively the patient recovered well with no neurologic deficits. CT head on the following day showed no significant infarctions. Histopathological examination of the aneurysm was suggestive of thrombosed wall of aneurysm with no evidence of inflammation or infection. OFA aneurysms are rare and have been reported along with associated vascular malformations and multiple aneurysms.[1] We report an isolated case of a partially thrombosed distal OFA aneurysm in a patient with no predisposing factors. As it was partially thrombosed and was arising from a small vessel, preoperatively it was mistakenly thought that it was arising from the A1 segment. However, only at surgery was the exact nature of the aneurysm defined. It is important to distinguish RAH from the OFA. The RAH usually originates within 4 mm of Acom region (most commonly in the proximal 0.5 mm of A2). Usually it is single but rarely can be duplicated or absent.[2] The OFA arises from the A2 about 5 mm from the AcomA junction. It then courses across the gyrus rectus and olfactory tract supplying the orbital gyri, gyrus rectus and the olfactory tract and bulb. Hence, before sacrificing a vessel the above distinguishing points must be kept in mind, it is important to dissect the vessel distally to confirm that it is not RAH prior to sacrifice.

Xue MH, Chun HW, Li J, Song YL. Multiple aneurysms of distal anterior cerebral artery associated with a cerebral arteriovenous malformation. NeurolIndia 2010;58:968‑70. 2. Perlmutter D, Rhoton AL Jr.Microsurgicalanatomy of the anteriorcerebral‑anterior communicating‑recurrent artery complex. J Neurosurg1976;45:259‑72. Access this article online Quick Response Code:

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DOI: 10.4103/0976-3147.140017

Is staged surgery for giant vestibular schwannomas always better in improving outcome: Needs socioeconomic consideration? Sir, Bandlish et al. reported 12 cases of giant vestibular schwannomas (GAS) operated through a retrosigmoid approach in a staged manner over two consecutive days

Journal of Neurosciences in Rural Practice | October - December 2014 | Vol 5 | Issue 4

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Partially thrombosed distal orbitofrontal artery aneurysm mimicking an A1 segment aneurysm.

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