Heubner\'s artery territory infarction after surgical clipping of an unruptured saccular aneurysm of the left anterior cerebral artery: a case report

Clinical History

A 58-year-old male patient presented at the neurosurgery department for surgical clipping of an unruptured saccular aneurysm of the junction between the A1 and the A2 segments of the left anterior cerebral artery (ACA). The neurological assessment after the patient woke up from general anaesthesia revealed weakness of the right arm.

Imaging Findings

The unruptured saccular aneurysm of the junction between the A1 and the A2 segments of the left ACA was demonstrated with computed tomography angiography (CTA) (Fig. 1).The CTA was performed to investigate headaches of recent onset. A computed tomography examination (CT) of the brain 24 hours after the patient awoke, detected hypointense lesions in the head of the caudate nucleus, the anterior limb of the internal capsule and the anterior part of the putamen (Fig. 2).

Discussion

The recurrent artery of Heubner (RAH), also known as the medial striate artery or long central artery, is named after the German paediatrician Johann Otto Leonhard Heubner (1843-1926). The awareness of the various anatomical and morphometric variations of the RAH is essential in planning neurosurgical procedures to avoid neurological complications such as an ischaemic infarct. The RAH supplies blood to the anterior portion of the caudate nucleus, the anterior third of the putamen, the external segment of the globus pallidus and the anterior crus of the internal capsule. It is the largest vessel of the medial lenticulostriate arteries and the only one routinely seen on angiography. The RAH is branching from A1, from A2 or from the junction between the A1 and the A2 segments of the ACA. Later the artery turns posteriorly, runs parallel and is anterior to A1, which is why it is at risk from A1-A2 ACA junction aneurysm clipping. The course of the RAH is closely related to the posterior portion of the orbitofrontal cortex and mainly to the gyrus rectus. The artery passes inferiorly and laterally to the origin of olfactory striae before reaching the anterior perforating substance [1]. The anatomical variations of RAH are related to its presence or absence, number and the diverse origin from ACA and are of considerable clinical impact mainly from the point of view of the surgical procedures involving the anterior portion of the circle of Willis. In a study of 69 human brain hemispheres, RAH was absent in 6%.The origin of the RAH was 62, 3% from the A1-A2 junction, 23, 3% from the proximal A2 segment and 14, 3% from the A1 segment of ACA. The mean outer diameter was 0.8 mm and the mean length 24 mm [2]. The procedure of aneurysm clipping involves placing a surgical clip at the junction of the healthy artery and the neck of the aneurysm. Although this treatment is very effective (demonstrated by annual risk of rupture reported from 0% to 0.9%), in a study of 143 patients, procedure-related complications were diagnosed in 20.3% [3]. We did not find any published study about the frequency of RAH's territory infarct after surgical clipping of ACA aneurysm. CT of the brain is an easily accessible imaging method to detect these ischaemic infarcts, but it has low sensitivity in the first 24 hours [4].

Differential Diagnosis List

Final Diagnosis

Left Heubner's artery territory infarct

URL:	https://www.eurorad.org/case/12761
DOI:	10.1594/EURORAD/CASE.12761
ISSN:	1563-4086