• Christoph Schwartz, Behnam Rezai Jahromi, Ahmad Hafez, Jussi Numminen, Martin Lehecka, and Mika Niemelä.
• Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Finland; Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria. Electronic address: ext-christoph.schwartz@hus.fi.
• World Neurosurg. 2019 Sep 1; 129: 101-104.

BackgroundMirror distal anterior cerebral artery aneurysms (DACAAs) are a rare finding in patients with subarachnoid hemorrhage, with only a few cases reported.Case DescriptionA 40-year-old man was admitted for sudden-onset headache, nausea and vomiting, and transient right arm hypoesthesia. Computed tomography scan showed a subarachnoid hemorrhage with intracerebral hemorrhage within the interhemispheric fissure, but computed tomography angiography failed to identify any aneurysms. Subsequent digital subtraction angiography with three-dimensional reconstructions revealed 1.5-mm-diameter mirror DACAAs on the A3 segments. However, the definite rupture site remained unidentifiable. After interdisciplinary consultation, endovascular treatment was favored, and complete occlusion of both DACAAs was achieved by coiling without stent placement. During coiling of the right DACAA, a thrombus in the right callosomarginal artery formed, and treatment with abciximab (ReoPro) was initiated to dissolve the thrombus. After treatment, the patient presented with right leg paresis; however, computed tomography did not show any ischemia, intracerebral hemorrhage increase, or vasospasm. Over the following days, the leg paresis improved, and the patient achieved increased mobilization. He was transferred for further rehabilitation 16 days after hemorrhage. The leg paresis had recovered to a grade 3/5.ConclusionsRapid identification of the rupture site in patients with subarachnoid hemorrhage and multiple aneurysms is crucial for initiating optimal treatment. In patients with mirror aneurysms in close proximity to each other, this is not easily accomplished, complicating treatment decisions. Although clipping has been the standard for DACAA occlusion, coiling should be taken into consideration as a viable alternative.Copyright © 2019 Elsevier Inc. All rights reserved.

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