LETTER TO EDITOR Year : 2023  |  Volume : 71  |  Issue : 4  |  Page : 800-801

Does Gyrus Rectus Bleed Always Means ACA Territory Aneurysm? Importance of Viewing CT Angiogram in Console

Vishal M Pishe1, Veda C Sawalgi2, Anu Kapoor2, Alugolu Rajesh1, M Vijaya Saradhi1
1 Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
2 Department of Radiology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India

Date of Submission22-Jul-2022Date of Decision10-Mar-2023Date of Acceptance20-Mar-2023Date of Web Publication18-Aug-2023

Correspondence Address:
Alugolu Rajesh
Additional Professor, Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Telangana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0028-3886.383868

How to cite this article:
Pishe VM, Sawalgi VC, Kapoor A, Rajesh A, Saradhi M V. Does Gyrus Rectus Bleed Always Means ACA Territory Aneurysm? Importance of Viewing CT Angiogram in Console. Neurol India 2023;71:800-1
How to cite this URL:
Pishe VM, Sawalgi VC, Kapoor A, Rajesh A, Saradhi M V. Does Gyrus Rectus Bleed Always Means ACA Territory Aneurysm? Importance of Viewing CT Angiogram in Console. Neurol India [serial online] 2023 [cited 2023 Aug 21];71:800-1. Available from: https://www.neurologyindia.com/text.asp?2023/71/4/800/383868

Sir,

Hematomas in the gyrus rectus are sine-qua-none of anterior cerebral artery (ACA) territory aneurysm/vascular malformation. We here report a case of a 40-year-old female patient with non-contrast computed tomography (NCCT) brain s/o right gyrus rectus bleed with an aneurysm arising from the contralateral paraclinoid internal carotid artery (ICA) aneurysm.

Gyrus rectus-The portion of the inferior frontal lobe immediately adjacent to the longitudinal fissure (and medial to the medial orbital gyrus and olfactory tract) is named the gyrus rectus or straight gyrus and is continuous with the superior frontal gyrus on the medial surface. A specific function for the straight gyrus has not yet been brought to light.

Common causes of hematoma in gyrus rectus documented in literature:

Ruptured aneurysm in ACA territory.Ruptured anterior ethmoidal artery aneurysm,[1]Ruptured superior hypophyseal artery aneurysm.

Paraclinoid ICA aneurysms are defined as aneurysms originating from the clinoidal and ophthalmic segments of the ICA, and constitute between 5% and 14% of all intracranial aneurysms.[2]

Rupture aneurysm in the ICA territory generally causes subarachnoid hemorrhage (SAH) in a basal cistern, and in the ACA territory causes SAH in interhemispheric fissure or may present with gyrus rectus bleed. Ruptured aneurysms with a presentation of intracerebral hemorrhage (ICH) and/or intraventricular hemorrhage (IVH) are rarely reported.[3]

In this case, the patient had a left paraclinoid aneurysm, which grew medially causing compression over the optic track leading to vision loss and rupture causing contralateral (rt side) gyrus rectus bleeding [Figure 1].

Figure 1: (a) A-Plain CT brain (axial) show well-defined hyperdense area with adjacent edema noted in the gyrus rectus region on the right side with intraventricular extension into bilateral lateral ventricles, (b) CT angiogram brain (MIP) showing aneurysm seems to arise from the ACA territory, (c) CT angiogram (VRT image) showing aneurysm arising from left paraclinoid ICA, (d) (postoperative) CT brain axial show craniotomy defect in left fronto-parietal bones with acute bleed at right gyrus rectus, (e and f) CT brain angiogram MIP and VRT images show the absence of aneurysm with the metallic aneurysmal clip at supraclinoid region on left side

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The usual thought process is to evacuate the hematoma and create space for easy clipping. However, this would have created havoc as the aneurismal neck was beneath the clinoid of the contralateral side. Many times the neurosurgeons look at the films provided rather than analyzing the angiogram on the console while processing.

  Conclusion 

This case brings to light an unusual presentation of a ruptured paraclinoid ICA aneurysm and the need for careful evaluation of CT angiograms preferably in the console by the treating neurosurgeons.

Acknowledgment

The authors are pleased to acknowledge their invaluable support for the conduction of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Li G, Zhu X, Zhang Y, Zhao J, Jinchuan Z, Gao X, et al. Aneurysmal isolated intracerebral hemorrhage and/or intraventricular hemorrhage without subarachnoid hemorrhage: A rare and perplexing scenario in neurosurgical practice. ChinNeurosurg J 2016;2:23.  
    2.Godbole C, Behari S, Bhaisora KK, Sardhara J, Srivastava A, Mehrotra A, et al. Surgery for superior hypophyseal artery aneurysms: A new classification and surgical considerations. Neurol India 2017;65:588–99.  
[PUBMED]  [Full text]  3.Du R, Day A. Microsurgery of paraclinoid aneurysms. In: Youmans JR, editor. Neurological Surgery, vol 4. 6th ed. Philadelphia: WB Saunders; 2011. p. 3824–33.  
    
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