Microsurgical anatomy of the anterior cerebral-anterior communicating-recurrent artery complex

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✓ The microvascular relationships important to surgery of aneurysms in the anterior communicating region were defined in 50 cadaver brains. The recurrent artery of Heubner was frequently exposed before the A-1 segment in defining the neck on anterior cerebral aneurysms because it commonly courses anterior to A-1. It arose from the A-2 segment of the anterior cerebral artery (ACA) in 78% and most commonly terminated in the area of the anterior perforated substance, and lateral to it in the Sylvian fissure. The anterior communicating artery (ACoA) frequently gave rise to perforating arteries which terminated in the superior surface of the optic chiasm and above the chiasm in the anterior hypothalamus. This finding contrasts with previous reports that no perforating branches arise from the communicating artery. The proximal half of the A-1 segment was a richer source of perforating arteries than the distal half. The A-1 branches most commonly terminated in the anterior perforated substance, the optic chiasm, and the region of the optic tract. The ACoA increased in size as the difference in the diameter between the right and left A-1 segments increased. Frequent variants such as double or triple ACoA's, triple A-2 segments, and duplication of the A-1 segments were encountered. The clinical consequences of occlusion of the recurrent artery and of the perforators from the ACoA and medial and lateral segment of A-1 are reviewed.

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Address reprint requests to: Albert L. Rhoton, Jr., M.D., Neurosurgery, University of Florida Health Center, Gainesville, Florida 32610.

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Figures

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    Three anterior views of A-1 and proximal A-2 segments of the ACA, ACoA, and recurrent arteries. Gyrus rectus, olfactory tract, and frontal lobe above; optic nerves and chiasm below. Arterioles to optic nerves, chiasm and tracts, and lamina terminalis arise from the ACA and ACoA. A. A-1 segments of equal size and small communicating artery pass above the optic chiasm. Recurrent arteries arise from lateral side of A-2. Recurrent arteries pass anterosuperior to A-1. B. Both A-2 segments arise from large left A-1. Right A-1 small. A-1 segments pass above the optic nerves. Recurrent arteries arise from A-2 segments. Right recurrent is longer than A-1 segment. Left recurrent passes superior to A-1. Branches of ACoA supply the lamina terminalis above optic chiasm. C. A-1 segments are connected by three small communicating arteries. Both recurrent arteries arise from A-1 segments; the left passes superior and posterior to A-1, and the right courses anterior and superior to A-1. Continued overleaf.

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    (continued). Three anterior views of A-1 and proximal A-2 segment of the ACA, ACoA, and recurrent arteries. Gyrus-rectus, olfactory tract, and frontal lobe above; optic nerves and chiasm below. Arterioles to optic nerves, chiasm and tracts, and lamina terminalis arise from the ACA and ACoA. D. A-1 segments are connected by double communicating artery. Right recurrent artery arises from A-2 and courses above A-1. Left arises from A-1 and passes anterior to A-1. Multiple arterioles pass to optic chiasm and tract. E. A-1 segments are connected by double communicating artery. Two recurrent arteries arise on right; one arises proximal and one distal to the communicating. Left recurrent artery arises from posterior aspect of A-1. Spray of arterioles passes from communicating to optic chiasm. F. Multichanneled ACoA gives rise to multiple arterioles to the optic nerves and chiasm and lamina terminalis. Double recurrent artery on right. Left recurrent gives rise to a large branch which passes below gyrus rectus to frontal tip.

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    (continued). Three anterior views of A-1 and proximal A-2 segments of the ACA, ACoA, and recurrent arteries. Gyrus rectus, olfactory tract, and frontal lobe above; optic nerves and chiasm below. Arterioles to optic nerves, chiasm and tracts, and lamina terminalis arise from the ACA and ACoA. G. Left A-1 segment is split into a double channel. Both A-2 segments arise predominantly from right A-1. Left recurrent artery arises from one of the two A-1 segments on left. Right recurrent artery arises from A-2. H. Triple A-2 segments arise from communicating artery area. Left recurrent artery arises from A-1 segment; right from junction of A-1 and A-2 segments. I. Tortuous A-1 segments loop forward to area of tuberculum sellae. Left recurrent artery arises from A-2 segment and right from A-1.

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    Left: Tortuous anterior cerebral-anterior communicating complex loops anterior to optic chiasm between optic nerves. Large right A-1 supplies both A-2 segments. Proximal A-2 on left gives rise to a branch to gyrus rectus medial to olfactory nerve (CNI). Right: Arteries lifted away from optic chiasm and nerves show small left A-1.

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    A-1 segments and communicating artery are of equal size. Left recurrent artery and a branch passing to frontal tip arise from A-1. Right recurrent artery arises at level of the communicating artery.

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    Multiple small arteries passing to superior surface of optic chiasm arise from ACA's. Broad communicating artery is split into multiple channels. Right A-2 passes into longitudinal fissure anterior to left A-2.

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    Small ACoA connects right and left A-1 segments of nearly equal diameter. Larger communicating arterial channel is connected to left A-1 segment by a rudimentary channel. Large left recurrent artery arises from A-1. Multiple arterioles supply dorsal surface of chiasm. Left A-2 passes anterior to right A-2 as A-2 segments enter the longitudinal fissure.

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    Right A-1 is larger than left and gives rise to both A-2 segments. Communicating artery is split into a double channel by a small hole. Left A-1 gives rise to a large branch passing to frontal tip. Double communicating channel arising from right A-1 is connected to left A-1 by a rudimentary channel. Left recurrent artery passes anterior to A-1.

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    Both A-1 segments and ACoA are of approximately equal size. Right A-1 segment, medial half, splits into two channels and recurrent artery arises from one of these.

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    Three A-2 segments arise from communicating area. Right recurrent artery arises from right A-2 and the left recurrent artery from middle A-2.

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    A-1 segments are of equal diameter. Communicating artery is smaller than A-1 segments. Communicating artery gives rise to small arterioles passing to optic chiasm and lamina terminalis. Tortuous left recurrent artery passes anterior to A-1. Right recurrent artery passes posterior to A-1 segment.

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    A-1 segments are connected by two communicating arteries. Right recurrent artery passes lateral to upper surface of carotid bifurcation and enters Sylvian fissure above the middle cerebral artery.

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    Right and left A-1 are of nearly equal diameter. Double communicating artery: one is small and the other rudimentary. Left recurrent artery passes above A-1. Right recurrent artery courses superior and posterior to A-1.

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