Tag: Anterior communicating artery

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Fenestrated clipping of previously coiled posterior‑superiorly projecting anterior communicating artery aneurysms

Acta Neurochirurgica (2024) 166:395

Anterior communicating artery (ACOM) aneurysms are among the most common aneurysms associated with aneurysmal subarachnoid hemorrhage (International Study of Unruptured Intracranial Aneurysms I (N Engl J Med 339:17251733, 1998), Wiebers (Lancet 362:103-110, 2003)). Surgical clipping of posterior-superiorly projecting ACOM aneurysms can be challenging, as the ipsilateral A2 can interfere with clip trajectory and ACOM perforating vessels obstructed from view. Intraluminal coils can further increase the difficulty of the procedure.

Method The relevant surgical anatomy with illustration is presented. A video detailing our technique on an illustrative case is provided.

Conclusion Surgical clipping of posterior-superiorly projecting ACOM aneurysms can require complex clip configurations. We describe the key steps of posterior-superiorly projecting ACOM aneurysm clipping through a lateral supraorbital craniotomy and fenestrated tandem clipping.

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Clipping Could Be the Best Treatment Modality for Recurring Anterior Communicating Artery Aneurysms Treated Endovascularly

Neurosurgery 90:627–635, 2022

The anterior communicating artery (AcoA) is the most common location for intracranial aneurysms.

OBJECTIVE: To present occlusion outcomes, complication rate, recurrence rate, and predictors of recurrence in a large cohort with AcoA aneurysms treated primarily with endosaccular embolization. We also attempt to present data on the most effective treatment modality for recurrent AcoA aneurysms.

METHODS: This is a retrospective, single-center study, reviewing the outcomes of 463 AcoA aneurysms treated endovascularly between 2003 and 2018.

RESULTS: The study cohort consisted of 463 patients. Adequate immediate occlusion was achieved in 418 (90.3%). Independent functional status at discharge was observed in 269 patients (58.0%), and the mortality rate was 6.8% (31). At 6 months, adequate occlusion was achieved in 418 (90.4%). Of all the patients, recurrence was observed in 101 cases (21.8%), and of those, 98 (22.4%) underwent retreatment. The combined frequency of retreatment for the coiling group was 42.4%, which was significantly higher than the 0 incident of retreatment in the clipping group (P < .0001). Among the retreatment cohort, there was a significantly higher subsequent retreatment rate in the endovascular group (0% in the clipping group vs 42.4% in the endovascular group, P < .0001).

CONCLUSION: Coiling with and without stent/balloon assistance is a relatively safe and effective modality for the treatment of AcoA aneurysms; however, in the setting of recurrence, microsurgical reconstruction leads to improved outcomes regarding durable occlusion, thus avoiding the potential for multiple interventions in the future.

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Anterior Communicating Artery Aneurysm Morphology and the Risk of Rupture

World Neurosurg. (2018) 109:119-126.

Recently, with improvements in computed tomography angiography and digital subtraction angiography, the assessment of certain morphologic traits of anterior communicating artery aneurysms (ACoAA) has drawn great attention. The determination of specific factors associated with rupture would provide much-needed guidance for the treatment of unruptured intracranial aneurysms, such as surgical clipping or endovascular coiling. Morphologic factors include, but are not limited to, aneurysm size, number, shape, dome direction, neck/dome ratio, and relationship of the aneurysm to the surrounding vessels. However, the results of previous investigations concerning morphologic parameters have yielded inconsistent results.

METHODS: This review presents and analyzes the literature on the morphology of ACoAAs and risk of rupture.

RESULTS: This literature review reveals that the strongest predictors of ACoAA rupture are size ratio, direction of the dome, and fenestration. These were the only factors that were either unanimously or near unanimously found to be predictive of rupture across multiple studies.

CONCLUSIONS: The size ratio, direction of the dome, and fenestration should be examined most meticulously when deciding when to treat an ACoAA.

 

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Clinical relevance of anterior cerebral artery asymmetry in aneurysmal subarachnoid hemorrhage

J Neurosurg 127:1070–1076, 2017

An asymmetry of the A1 segments (A1SA) of the anterior cerebral arteries (ACAs) is an assumed risk factor for the development of anterior communicating artery aneurysms (ACoAAs). It is unknown whether A1SA is also clinically relevant after aneurysm rupture. The authors of this study investigated the impact of A1SA on the clinical course and outcome of patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS The authors retrospectively analyzed data on consecutive SAH patients treated at their institution between January 2005 and December 2012. The occurrence and severity of cerebral infarctions in the ACA territories were evaluated on follow-up CT scans up to 6 weeks after SAH. Moreover, the risk for an unfavorable outcome (defined as > 3 points on the modified Rankin Scale) at 6 months after SAH was assessed.

RESULTS A total of 594 patients were included in the final analysis. An A1SA was identified on digital subtraction angiography studies from 127 patients (21.4%) and was strongly associated with ACoAA (p < 0.0001, OR 13.7). An A1SA independently correlated with the occurrence of ACA infarction in patients with ACoAA (p = 0.047) and in those without an ACoAA (p = 0.015). Among patients undergoing ACoAA coiling, A1SA was independently associated with the severity of ACA infarction (p = 0.023) and unfavorable functional outcome (p = 0.045, OR = 2.4).

CONCLUSIONS An A1SA is a common anatomical variation in SAH patients and is strongly associated with ACoAA. Moreover, the presence of A1SA independently increases the likelihood of ACA infarction. In SAH patients undergoing ACoAA coiling, A1SA carries the risk for severe ACA infarction and thus an unfavorable outcome.

 

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Is there an inherited anatomical conformation favoring aneurysmal formation of the anterior communicating artery?

J Neurosurg 126:1598–1605, 2017

The pathophysiological mechanisms responsible for the formation of intracranial aneurysms (IAs) remain only partially elucidated. However, current evidence suggests a genetic component. The purpose of this study was to investigate the specific anatomical variations in the arterial complex that are associated with the presence of anterior communicating artery (ACoA) aneurysms in the familial forms of IAs.

METHODS This multicenter study investigated bifurcation IAs in patients who had a sporadic ACoA IA without a family history of IA (SACAA group), in patients who had an ACoA IA with a family history of IA (FACAA group), and in their healthy first-degree relatives (HFDRs). Through the use of MR angiography (MRA) reconstructions, the symmetry of the A1 segments and the angle between the A1 and A2 segments were analyzed on 3D models for each group. These measurements were then compared among the 3 groups.

RESULTS Twenty-four patients with SACAA, 24 patients with FACAA, and 20 HFDRs were included in the study. Asymmetrical configuration of the A1 segments was more frequent in the FACAA group than in the HFDR group (p = 0.002). The aneurysm-side A1-A2 angle was lower in the FACAA group (p = 0.003) and SACAA group (p = 0.007) than in the HFDR group. On the contralateral side, there was no difference in A1-A2 angles between groups.

CONCLUSIONS The anatomical shape of the ACoA complex seems to be similarly associated with the presence of ACoA IAs in both the FACAA and SACAA groups. This highlights the role played by hemodynamic constraints in aneurysm formation and questions the hypothesis of the hereditary character of these anatomical shapes.

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Analysis of superiorly projecting anterior communicating artery aneurysms

Analysis of superiorly projecting anterior communicating artery aneurysms

Neurosurg Rev (2016) 39:225–235

Superiorly projecting (SP) anterior communicating artery (AComA) aneurysms are typically described as a homogenous group. Clinically and microsurgically, these aneurysms vary in multiple important characteristics.

We propose a microsurgical classification system for these complex aneurysms and review its implications regarding presentation, microsurgical techniques, and outcome.

This retrospective analysis reviews patients undergoing clipping of SP AComA aneurysms (2005–2013). The classification system is based on the virtual plane created by the A2 segments and its relationship to the aneurysm. Aneurysm type was assessed by intraoperative images and videos. Type 1 is defined by bisection of the dome by the virtual plane. Type 2 is defined by dome projection posterior to this plane. Sagittal rotation of the plane defines type 3. We analyzed clinical presentation, morphology, angiographic characteristics, operative technique, and outcome relative to the classification types.

There were 44 SP AComA aneurysms. 3D angiographic images predicted classification type in 83 %. Type 1 presented more often with SAH (95.5 %, p=0.0046). There was no statistically significant difference between the types regarding patient demographics or aneurysm characteristics. In type 2, fenestrated clips were used frequently (87.5 % p=0.0016), and there was higher rate of intraoperative rupture (37.5 %). Although there was no statistically significant difference between the types in respect to HH grade upon presentation, patients with type 2 aneurysms experienced higher rates of poor GOS (50 %).

The proposed classification system for SP AComA aneurysms has implications regarding surgical planning, micro-dissection, clipping, and outcome. Type 2 aneurysms carry significant surgical risk.

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Height of aneurysm neck and estimated extent of brain retraction: powerful predictors of olfactory dysfunction after surgery for unruptured anterior communicating artery aneurysms

Height of aneurysm neck and estimated extent of brain retraction- powerful predictors of olfactory dysfunction after surgery for unruptured anterior communicating artery aneurysms

J Neurosurg 124:720–725, 2016

The highest incidence of olfactory dysfunction following a pterional approach and its modifications for an intracranial aneurysm has been reported in cases of anterior communicating artery (ACoA) aneurysms. The radiological characteristics of unruptured ACoA aneurysms affecting the extent of retraction of the frontal lobe and olfactory nerve were investigated as risk factors for postoperative olfactory dysfunction.

Methods A total of 102 patients who underwent a pterional or superciliary keyhole approach to clip an unruptured ACoA aneurysm from 2006 to 2013 were included in this study. Those patients who complained of permanent olfactory dysfunction after their aneurysm surgery, during a postoperative office visit or a telephone interview, were invited to undergo an olfactory test, the Korean version of the Sniffin’ Sticks test. In addition, the angiographic characteristics of ACoA aneurysms, including the maximum diameter, the projecting direction of the aneurysm, and the height of the neck of the aneurysm, were all recorded based on digital subtraction angiography and sagittal brain images reconstructed using CT angiography. Furthermore, the extent of the brain retraction was estimated based on the height of the ACoA aneurysm neck.

Results Eleven patients (10.8%) exhibited objective olfactory dysfunction in the Sniffin’ Sticks test, among whom 9 were anosmic and 2 were hyposmic. Univariate and multivariate analyses revealed that the direction of the ACoA aneurysm, ACoA aneurysm neck height, and estimated extent of brain retraction were statistically significant risk factors for postoperative olfactory dysfunction. Based on a receiver operating characteristic (ROC) analysis, an ACoA aneurysm neck height > 9 mm and estimated brain retraction > 12 mm were chosen as the optimal cutoff values for differentiating anosmic/hyposmic from normosmic patients. The values for the area under the ROC curves were 0.939 and 0.961, respectively.

Conclusions In cases of unruptured ACoA aneurysm surgery, the height of the aneurysm neck and the estimated extent of brain retraction were both found to be powerful predictors of the occurrence of postoperative olfactory dysfunction.

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A Reappraisal of Anterior Communicating Artery Aneurysms: A Case for Stent-Assisted Embolization

Anterior Communicating Artery Aneurysms- A Case for Stent-Assisted Embolization

Neurosurgery 78:200–207, 2016

Wide-necked anterior communicating artery aneurysms represent a subset of lesions with challenging endovascular treatment despite new endoluminal and intrasaccular devices.

OBJECTIVE: To assess the long-term clinical and angiographic outcomes of stentassisted embolization for wide-necked anterior communicating artery aneurysms.

METHODS: Between March 2008 and March 2014, 32 patients with unruptured widenecked AComm aneurysms were treated using stent-assisted embolization. The Glasgow Outcome Scale was reviewed at the time of discharge and at latest follow-up. Ischemic and hemorrhagic events were also recorded and analyzed. Aneurysm occlusion was evaluated post-intervention and on subsequent follow-up evaluations.

RESULTS: Successful stent deployment was achieved in all cases, but in 1 patient the coils could not be contained inside the aneurysm, and the procedure was aborted without complications. The distal segment of the stent was positioned in the ipsilateral A2 in 16 patients, in the contralateral A2 in 15 patients, and in the contralateral A1 in 1 patient. There were no periprocedural thromboembolic or hemorrhagic complications. The rate of major complications was 6%. One patient developed intracranial hemorrhage related to antiplatelet therapy and another had ischemic events due to in-stent stenosis. Angiographic follow-up was available for 26 aneurysms and during a mean follow-up of 22 months, 81% of the lesions were completely occluded and 8% had a small residual neck. The retreatment rate for residual aneurysms was 3%.

CONCLUSION: Our long-term results suggest that stent-assisted embolization for anterior communicating artery aneurysms may be considered an excellent treatment option with an adequate combination of safety profile and effectiveness.

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The A1-A2 Diameter Ratio May Influence Formation and Rupture Potential of Anterior Communicating Artery Aneurysms

AComAA

Neurosurgery 73:845–853, 2013

Specific morphological factors contribute to the hemodynamics of the anterior communicating artery (AComA). No study has examined the role of the A2 segment on AComA aneurysm presence and rupture.

OBJECTIVE: To examine the possibility that the ratio between A1 and A2 segments (A1-2 ratio) represents an independent risk factor for presence and rupture of AComA aneurysms (AComAAs).

METHODS: A retrospective review of an institutional aneurysm database was performed; patients with ruptured and unruptured AComAAs were identified. Two control groups were selected: group A (posterior circulation aneurysms) and group B (patients without intracranial aneurysms or other vascular malformations). Measurements of A1 and A2 diameters were obtained from digital subtraction angiography (64.1% of 3-D rotational digital subtraction angiography), and the A1-2 ratio calculated.

RESULTS: From January 2009 to April 2011, 156 patients were identified (52 AComAAs, 54 control group A, and 50 control group B). Mean age at the time of presentation was 56.09 years. Compared with both control groups, patients with AComAAs had greater A1 diameter (P < .01) and A1-2 ratio (P < .001) and smaller A2 diameter (P < .01). The A1-2 ratio correlated positively with the presence of AComAAs (P < .001). Ruptured AComAAs were smaller than unruptured ones (5.91 mm vs 9.25 mm, P = .02) and associated with a higher A1-2 Ratio (P = .02). The presence of a dominant A1 did not predict AComAA rupture (P = .15). The A1-2 ratio correlated positively with the presence of ruptured AComAAs (P = .04).

CONCLUSION: A1-2 ratio correlates positively with the presence and rupture of AComAAs and may facilitate treatment decision in cases of small, unruptured AComAAs.

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Morphological and clinical risk factors for the rupture of anterior communicating artery aneurysms

Anterior communicating artery aneurysm rupture

J Neurosurg 118:978–983, 2013

Patients with ruptured anterior communicating artery (ACoA) aneurysms have historically been observed to have poor neuropsychological outcomes, and ACoA aneurysms have accounted for a higher proportion of ruptured than unruptured aneurysms. Authors of this study aimed to investigate the morphological and clinical characteristics predisposing to ACoA aneurysm rupture.

Methods. Data from 140 consecutive patients with ACoA aneurysms managed at the authors’ facility between July 2003 and November 2011 were retrospectively reviewed. Patients with (78) and without (62) aneurysm rupture were divided into groups, and morphological and clinical characteristics were compared. Morphological characteristics were evaluated based on 3D CT angiography and included aneurysm location, dominance of the A1 portion of the anterior cerebral artery, direction of the aneurysm dome around the ACoA, aneurysm bleb(s), size of the aneurysm and its neck, aneurysm–parent artery angle, and existence of other intracranial unruptured aneurysms.

Results. Patients with ruptured ACoA aneurysms were significantly younger (a higher proportion were younger than 60 years of age) than those with unruptured lesions, and a significantly smaller proportion had hypercholesterolemia. A significantly larger proportion of patients with ruptured aneurysms showed an anterior direction of the aneurysm dome around the ACoA, had a bleb(s), and/or had an aneurysm size ≥ 5 mm. Multivariate logistic regression analysis showed that an anterior direction of the aneurysm dome around the ACoA (OR 6.0, p = 0.0012), the presence of a bleb(s) (OR 22, p < 0.0001), and an aneurysm size ≥ 5 mm (OR 3.16, p = 0.035) were significantly associated with ACoA aneurysm rupture.

Conclusions. Findings in the present study demonstrated that the anterior projection of an ACoA aneurysm may be related to rupturing. The authors would perhaps recommend treatment to patients with unruptured ACoA aneurysms that have an anterior dome projection, a bleb(s), and a size ≥ 5 mm.

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Anterior Communicating Artery Aneurysm Clipped Via an Endoscopic Endonasal Approach

Neurosurgery 68[ONS Suppl 2]:ons310–ons316, 2011 DOI: 10.1227/NEU.0b013e3182117063

The anterior communicating artery (AcoA) aneurysm is one of the most challenging aneurysms. As endovascular techniques evolve, a remaining challenge is the reduction of complications related to the surgical approach. Although the endonasal approach is widely used for pituitary adenomas and is increasingly popular for suprasellar tumors, only 2 aneurysm cases have been reported.

OBJECTIVE: To the best of our knowledge, we are reporting the first case of successful endoscopic endonasal clipping of an unruptured ACoA aneurysm.

METHODS: An ACoA aneurysm was discovered in a 55-year-old man before he was to undergo an endoscopic biopsy of an orbital lesion. Because of the operative corridor formed during this first operation and ideal conformation of the aneurysm for this line of sight, we formulated an endoscopic route for this ACoA aneurysm.

RESULTS: An endoscopic endonasal transplanum-transtuberculum approach was performed. Proximal and distal control was obtained, and the AcoA aneurysm was successfully clipped. The postoperative course was uneventful with a rapid recovery.

CONCLUSION: On the road of innovation in the treatment of intracranial aneurysms, the endoscopic approach provided another option whose value must be weighed in terms not only of feasibility but in the patient’s best interest. We caution extreme prudence if considering this procedure as an alternative to well-established techniques. Yet its upward route offers limited retraction for deep-seated lesions. Rapid progress of endoscopic techniques may prove promising for well-selected cases of ACoA aneurysms.

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