Mirror image aneurysms of the distal anterior cerebral arteries (DACA) and middle cerebral arteries (MCA) are very rare. Only several cases are treated by endovascular embolization. We successfully treated double mirror image aneurysms at DACA and MCA in a patient.
A 65-year-old female patient transferred to ER from other hospital who had complained of severe headache and vomiting. Subarachnoid hemorrhage was found around the anterior interhemispheric fissure and multiple intracranial aneurysms were revealed by CT & MRA. DSA showed four aneurysms (double mirror image aneurysms at bilateral DACA and MCA). One of the aneurysms at DACA was considered as source of bleeding. We embolized both DACA aneurysms sequentially in one procedure. Several weeks later, we clipped right MCA aneurysm. We re-embolized left DACA aneurysm due to recurrence by distal stenting method. Patient is tolerable for five years until now. 
Historically, DACA aneurysms have been treated more often with open surgery. However, there are difficulties in microsurgery of DACA aneurysms; a narrow surgical field and the need to sacrifice the bridging veins. In addition, it is very difficult to determine which one is cause of bleeding in case of mirror image aneurysm. So it is easy to rupture prematurely at the time of dissection around the aneurysm.
Particularly when the mirror image of the DACA aneurysm ruptures, embolization of both aneurysms during one procedure is suitable and allows better outcome for patient.

TREATMENT OF RUPTURED DOUBLE MIRROR IMAGE ANEURYSMS AT THE DISTAL ANTERIOR CEREBRAL ARTERIES AND MIDDLE CEREBRAL ARTERIES; CASE REPORT