Traumatic Entrapment of the Anterior Cerebral Artery—A Case Report

Traumatic entrapment of cerebral vessels has previously been described with basilar artery entrapment through longitudinal clival fractures. To our knowledge there are currently no reports in the literature of traumatic entrapment of the anterior cerebral artery.

We present a case where, as a result of a 20-foot fall, a 26-year-old man suffered multiple skull base and facial fractures including fractures through the sphenoid at the roof of the sphenoid sinus and into the clivus. This resulted in traumatic entrapment of the distal A1 and proximal A2 segments of the right anterior cerebral artery through the fracture at the roof of the sphenoid sinus.

The patient was initially treated conservatively, but developed ischemic symptoms including watershed infarcts between the anterior and middle cerebral artery territories. He also developed fluctuating motor weakness in the left lower extremity.

Subsequently, surgery was performed through a pterional craniotomy and orbital osteotomy. The frontal lobes were gently retracted and the fracture visualized medial to the optic track. The right anterior cerebral artery could be seen tracking inferiorly at the point of herniation through the fracture. The dura was opened and the roof of the sphenoid sinus and posterior ethmoid sinus was drilled using a 3-mm diamond tip to a thin bone layer that was carefully dissected off to free the anterior cerebral artery. Retraction on the frontal lobes was tenuous due to tension on the entrapped vessel; it was minimized as much as possible.

Postoperatively the patient did well and regained motor function in the affected leg. He was independently ambulatory and doing well with no gross neurologic deficit at last follow-up.

This case represents the first report of a traumatic anterior cerebral artery entrapment. Although conservative management may be an option, the development of ischemic lesions or a neurologic deficit in the appropriate vascular territory warrants surgical management. Surgical management can be performed successfully with good neurologic outcome.