Anatomical triangles defining routes to anterior communicating artery aneurysms: the junctional and precommunicating triangles and the role of dome projection

OBJECTIVEAnterior communicating artery (ACoA) aneurysms are common intracranial aneurysms. Despite advances in endovascular therapy, microsurgical clipping remains an important treatment for aneurysms with broad necks, large size, intraluminal thrombus, complex branches, or previous coiling. Anatomical triangles identify safe corridors for aneurysm access. The authors introduce the A1-A2 junctional triangle and the A1-A1 precommunicating triangle and examine relationships between dome projection, triangular corridors of access, and surgical outcomes.METHODSPreoperative catheter and CT angiograms were evaluated to characterize aneurysm dome projection. Aneurysm projection was categorized into quadrants and octants. Preoperative, intraoperative, and postoperative factors were correlated to aneurysm dome projection and patient outcomes using univariate and multivariate analyses.RESULTSA total of 513 patients with microsurgically treated ACoA aneurysms were identified over a 13-year period, and 400 had adequate imaging and follow-up data for inclusion. Surgical clipping was performed on 271 ruptured and 129 unruptured aneurysms. Good outcomes were observed in 91% of patients with unruptured aneurysms and 86% of those with ruptured aneurysms, with a mortality rate < 1% among patients with unruptured aneurysms. Increasing age (p < 0.01), larger aneurysm size (p = 0.03), and worse preoperative modified Rankin Scale score (p < 0.01) affected outcomes adversely. Aneurysms projecting superiorly and posteriorly required dissection in the junctional triangle, and multivariate analysis demonstrated worse clinical outcomes in these patients (p < 0.01).CONCLUSIONSAnteriorly and inferiorly projecting aneurysms involve only the precommunicating triangle, are simpler to treat microsurgically, and have more favorable outcomes. Superior and posterior dome projections make ACoA aneurysms more difficult to visualize and require opening the junctional triangle. Added visualization through the junctional triangle is recommended for these aneurysms in order to facilitate dissection of efferent branch arteries, careful clip application, and perforator preservation. Dome projection can be determined preoperatively from images and can help anticipate dissection routes through the junctional triangle.

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Outcome of Microsurgical Clipping of Ruptured Anterior Circulation Aneurysms

Pakistan Journal Of Neurological Surgery ◽

10.36552/pjns.v23i4.383 ◽

2019 ◽

Vol 23 (4) ◽

Author(s):

MUHAMMAD JAHANGIR KHAN ◽

MUHAMMAD HAMMAD NASIR ◽

SIKANDAR ALI ◽

SARFRAZ KHAN ◽

MUHAMMAD WAQAS ◽

...

Keyword(s):

Anterior Communicating Artery ◽

Sex Distribution ◽

Surgical Clipping ◽

Anterior Circulation ◽

Efficient Treatment ◽

Microsurgical Clipping ◽

The Mean ◽

Anterior Circulation Aneurysms ◽

Grading Scales

Objective: The objective of the study was to analyze the operative outcome of microsurgical clipping in Ruptured Anterior Circulation Aneurysms.Materials and Methods: Twenty patients with Ruptured Anterior Circulation aneurysms were treated with surgical clipping. All the patients were evaluated pre-operatively according to Hunt & Hess and WFNS grading scales. Patients with grade I, II, and III were operated. All the aneurysms were clipped through Pterional approach under General anesthesia and Yasargil Aneurysm clips of appropriate sizes were used in each patient. Outcome was analyzed according to Glasgow Outcome Scale at the end of six months of follow up in each patient.Results: In this series of twenty cases, the mean patient age was 49 years. Lesion location included, the ACA/A. Com 55% (n = 11), the Middle Cerebral artery 25% (n = 5), P. Com 15% (n = 3), Ophthalmic artery 5% (n = 1). Sex distribution, female 55% (n = 11) and male 45% (n = 9). Per-operative complications, rupture of aneurysm 20% (n = 4), and damage to perforating branches of MCA 5% (n = 1). Conclusions: Surgical clipping still is the most efficient treatment of Ruptured Anterior Circulation aneurysm at the beginning of the new millennium. Anterior Communicating Artery is the commonest location of aneurysms. Major determinants of outcome are Hunt & Hess, WFNS grades on admission and the age of the patient.

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Optic neuropathy after anterior communicating artery aneurysm clipping: 3 cases and techniques to address a correctable pitfall

Journal of Neurosurgery ◽

10.3171/2017.2.jns162654 ◽

2018 ◽

Vol 128 (6) ◽

pp. 1808-1812 ◽

Cited By ~ 1

Author(s):

Joseph R. Linzey ◽

Kevin S. Chen ◽

Luis Savastano ◽

B. Gregory Thompson ◽

Aditya S. Pandey

Keyword(s):

Optic Nerve ◽

Vision Loss ◽

Treatment Options ◽

Artery Aneurysm ◽

Anterior Communicating Artery ◽

Mechanical Compression ◽

Visual Examination ◽

Microsurgical Clipping ◽

Complete Restoration

Brain shifts following microsurgical clip ligation of anterior communicating artery (ACoA) aneurysms can lead to mechanical compression of the optic nerve by the clip. Recognition of this condition and early repositioning of clips can lead to reversal of vision loss.The authors identified 3 patients with an afferent pupillary defect following microsurgical clipping of ACoA aneurysms. Different treatment options were used for each patient. All patients underwent reexploration, and the aneurysm clips were repositioned to prevent clip-related compression of the optic nerve. Near-complete restoration of vision was achieved at the last clinic follow-up visit in all 3 patients.Clip ligation of ACoA aneurysms has the potential to cause clip-related compression of the optic nerve. Postoperative visual examination is of utmost importance, and if any changes are discovered, reexploration should be considered as repositioning of the clips may lead to resolution of visual deterioration.

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Endovascular Treatment of ACom Intracranial Aneurysms

Interventional Neuroradiology ◽

10.1177/159101991001600101 ◽

2010 ◽

Vol 16 (1) ◽

pp. 7-16 ◽

Cited By ~ 20

Author(s):

S. Finitsis ◽

R. Anxionnat ◽

A. Lebedinsky ◽

P.C. Albuquerque ◽

M.F. Clayton ◽

...

Keyword(s):

Endovascular Treatment ◽

Additional Treatment ◽

Anterior Communicating Artery ◽

Anticoagulation Management ◽

Unruptured Aneurysms ◽

Anterior Communicating Artery Aneurysms ◽

Group 2 ◽

Group 1

The immediate and long-term outcomes, complications, recurrences and the need for retreatment were analyzed in a series of 280 consecutive patients with anterior communicating artery aneurysms treated with the endovascular technique. From October 1992 to October 2001 280 patients with 282 anterior communicating artery aneurysms were addressed to our center. For the analysis, the population was divided into two major groups: group 1, comprising 239 (85%) patients with ruptured aneurysms and group 2 comprising of 42 (15%) patients with unruptured aneurysms. In group 1, 185 (77.4%) patients had a good initial pre-treatment Hunt and Hess grade of I-III. Aneurysm size was divided into three categories according to the larger diameter: less than 4 mm, between 4 and 10 mm and larger than 10 mm. The sizes of aneurysms in groups 1 and 2 were identical but a less favorable neck to depth ratio of 0.5 was more frequent in group 2. Endovascular treatment was finally performed in 234 patients in group 1 and 34 patients in group 2. Complete obliteration was more frequently obtained in group 2 unlike a residual neck or opacification of the sac that were more frequently seen in group 1. No peri-treatment complications were recorded in group 2. In group 1 the peri-treatment mortality and overall peri-treatment morbidity were 5.1% and 8.1% respectively. Eight patients (3.4%) in group 1 presented early post treatment rebleeding with a mortality of 88%. The mean time to follow-up was 3.09 years. In group 1, 51 (21.7%) recurrences occurred of which 14 were minor and 37 major. In group 2, eight (23.5%) recurrences occurred, five minor and three major. Two patients (0.8%) presented late rebleeding in group 1. Twenty-seven second endovascular retreatments were performed, 24 (10.2%) in group 1 and three (8.8%) in group 2, seven third endovascular retreatments and two surgical clippings in group 1 only. There was no additional morbidity related to retreatments. Endovascular treatment is an effective method for the treatment of anterior communicating artery aneurysms allowing late rebleeding prevention. Peri-treatment rebleeding warrants caution in anticoagulation management. This is a single center experience and the follow-up period is limited. Patients should be followed-up in the long-term as recurrences may occur and warrant additional treatment.

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Cognitive Impairments and Associated Factors After Ruptured Anterior Communicating Artery Aneurysm Treatment in Low-Grade Patients <60 Years: A Multicenter Retrospective Study

10.21203/rs.3.rs-29771/v1 ◽

2020 ◽

Author(s):

Ning Ma ◽

Xin Feng ◽

Zhongxue Wu ◽

Daming Wang ◽

Aihua Liu

Keyword(s):

Regression Analysis ◽

Cognitive Impairment ◽

Cox Regression ◽

Cognitive Impairments ◽

Young Patients ◽

Endovascular Coiling ◽

Anterior Communicating Artery ◽

Cox Regression Analysis ◽

Microsurgical Clipping

Abstract Background Aneurysmal subarachnoid hemorrhage (SAH) is a kind of destructive cerebrovascular disease which could affect people's cognition, even the life expectancy. People with SAH are considered in a fatal situation, especially in the young population. This study aimed to investigate cognitive impairment and related factors in young patients with ruptured anterior communicating artery (ACoA) aneurysms.Methods We conducted a multicentre retrospective follow-up study at three hospitals in China. The young patients (18-50 years) who underwent ruptured ACoA aneurysm treatment by microsurgical clipping or endovascular coiling at three academic institutions in China from January 2015 to November 2017 were recruited. Patient cognition and life quality were assessed by using modified Telephone Interview for Cognitive Status (TICS-m), the modified Rankin Scale (mRS), and the instrumental activities of daily living (IADL) scale 2. Multiple cox-regression analysis was used to identify variables independently associated with cognitive impairment.Results Of the total of 59 patients, 54 (91.5%) achieved good clinical outcomes (mRS score 0-2) and 51 (86.4%) had excellent quality of life (IADL score 8). Ten (16.9%) patients showed cognitive impairments (TICS-m<27). The multivariate COX regression analysis showed that mRS scores of 3-5 at discharge, female sex, and aneurysm size <5 mm was independently associated with cognitive impairment. TICS-m scores at the latest follow-up were similar after open surgery and coiling. Conclusion In this relatively young sample that excluded patients with very poor-grade SAH or serious complications, microsurgical clipping led to better clinical outcomes than endovascular coiling, while cognitive outcomes were similar across treatment modalities. These results are not completely consistent with previous studies, and should therefore be considered in the clinical practice as well as further investigated in larger patient samples.

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Endovascular versus surgical treatment for improvement of oculomotor nerve palsy caused by unruptured posterior communicating artery aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-015802 ◽

2020 ◽

Vol 12 (10) ◽

pp. 964-967

Author(s):

Francesco Signorelli ◽

Raoul Pop ◽

Mario Ganau ◽

Helene Cebula ◽

Antonino Scibilia ◽

...

Keyword(s):

Nerve Palsy ◽

Univariate Analysis ◽

Oculomotor Nerve ◽

Posterior Communicating Artery ◽

Oculomotor Nerve Palsy ◽

Surgical Clipping ◽

Unruptured Aneurysms ◽

Significant Difference ◽

Complete Treatment

BackgroundThere is no consensus regarding the best treatment option for unruptured aneurysms of the posterior communicating artery (PCom) presenting with oculomotor nerve palsy (ONP). We aimed to assess predictors of ONP recovery in a multicenter series of consecutive patients.Materials and methodsA retrospective review of prospective databases in three tertiary neurosurgical centers was carried out, selecting patients with ONP caused by unruptured PCom aneurysms, treated by surgical clipping or embolization, between January 2006 and December 2013. Patient files and imaging studies were used to extract ophthalmological assessments, treatment outcomes, and follow-up data. Predictors of ONP recovery during follow-up were explored using univariate and multivariate analyses.ResultsWe identified 55 patients with a median ONP duration before treatment of 11 days (IQR 4.5–18); the deficit was complete in 27 (49.1%) and incomplete in 28 (50.9%) cases. Median aneurysm size was 7 mm (IQR 5–9). Twenty-four (43.6%) patients underwent surgical clipping and 31 (56.4%) embolization as the primary treatment. Overall, ONP improved in 40 (72.7%) patients and persisted/recurred in 15 (27.3 %). Surgery, interval to complete treatment <4 weeks, aneurysm recurrence during follow-up, and retreatment during follow-up were significantly correlated with ONP outcome in the univariate analysis. In the multivariate analysis, independent predictors of ONP improvement were interval to complete treatment <4 weeks (OR 5.15, 95% CI 1.37 to 23.71, p=0.015) and aneurysm recurrence during follow-up (OR 0.1, 95% CI 0.02 to 0.47, p=0.003).ConclusionThere was no significant difference in ONP recovery between surgical clipping and embolization. The best predictor for ONP recovery was timely, complete, and durable aneurysm exclusion.

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Intraoperative Rerupture and Surgical Clipping of a Small Superiorly Projecting Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa113 ◽

2020 ◽

Vol 19 (3) ◽

pp. E288-E288

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Video Recording ◽

Artery Aneurysm ◽

Anterior Communicating Artery ◽

Surgical Clipping ◽

Institutional Review ◽

Clip Application ◽

Interhemispheric Fissure ◽

Aneurysm Occlusion ◽

Intraoperative Rupture ◽

Temporary Clip

Abstract Anterior communicating artery (ACoA) aneurysms are prone to rupture even at smaller sizes. The surgical management of ACoA aneurysms is highly dependent on the spatial orientation of the saccular projection, categorized as inferior, superior, anterior, or posterior. Superior projecting aneurysms constitute approximately one-third of all aneurysms involving the ACoA. These aneurysms commonly project within the interhemispheric fissure; however, if the aneurysm is not high-riding, it can often be approached via a transsylvian trajectory. The patient presented after subarachnoid hemorrhage with a 3-mm superiorly projecting ACoA aneurysm. The lesion was approached via a right modified orbitozygomatic craniotomy with a transsylvian trajectory. The aneurysm reruptured after minimal manipulation of the dome. Mitigation of the intraoperative rupture was achieved through temporary clip application to bilateral A1 vessels. Bipolar coagulation and placement of 2 permanent clips facilitated final aneurysm occlusion. Postoperative imaging demonstrated patent bilateral A2 flow and no residual aneurysm filling. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Early Rebleeding of Small Anterior Communicating Artery Aneurysm with Presumed Extrusion of Coil Loop to outside the Aneurysmal Wall during Endovascular Treatment

Interventional Neuroradiology ◽

10.1177/159101990901500117 ◽

2009 ◽

Vol 15 (1) ◽

pp. 103-108 ◽

Cited By ~ 1

Author(s):

HW Pyun ◽

DK Hyun ◽

DH Lee ◽

SW Park ◽

MK Lim

Keyword(s):

Endovascular Treatment ◽

Coil Embolization ◽

Artery Aneurysm ◽

Anterior Communicating Artery ◽

Surgical Clipping ◽

Aneurysmal Wall ◽

Follow Up Study ◽

Complete Treatment ◽

Anterior Communicating Aneurysm

Although endovascular treatment has been proved to be as effective as surgical clipping in the prevention of rebleeding of ruptured aneurysm, early rebleeding after coil embolization has seldom been reported. We experienced early re-hemorrhage in two patients of ruptured small anterior communicating artery aneurysms of complete treatment with coil-embolization initially. In both cases what interested us was not early rebleeding itself but how the presumed extrusion of the first part of coil loop beyond aneurysmal wall developed. However, there was no evidence of intraprocedural rupture and moreover complete occlusion with only one or two coils was obtained. Our two patients underwent successful second treatment. We discovered the presumed extruded first part of the coil loop initially was located inside the enlarged aneurysmal sac in retreatment stage. In case of coil embolization of ruptured small anterior communicating aneurysm, the phenomenon we experienced with no evidence of intraprocedural rupture in spite of obvious extrusion of coil loop beyond the aneurysmal wall can be a sign of necessity for early follow-up study including plain radiography to track the change in the presumed extruded coil loop.

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Microsurgical clipping of the anterior circulation aneurysms

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v20i4.1001 ◽

2018 ◽

Vol 20 (4) ◽

pp. 409-414

Author(s):

Carlos Eduardo Da Silva ◽

Paulo Eduardo Peixoto De Freitas ◽

Alicia Del Carmen Becerra Romero ◽

Fáberson João Mocelin Oliveira ◽

Márcio Aloisio Bezerra Cavalcanti Rockenbach ◽

...

Keyword(s):

Relevant Literature ◽

Cerebral Aneurysms ◽

Series Data ◽

Anterior Communicating Artery ◽

Anterior Circulation ◽

Ruptured Aneurysms ◽

Microsurgical Clipping ◽

The Mean ◽

Anterior Circulation Aneurysms

Introduction: The authors present the analysis of the microsurgical clipping of 100 cerebral aneurysms of the anterior circulation and compare the series data with the literature. Methods: Eighty-eight patients presenting with 100 anterior circulation aneurysms operated on microsurgical techniques between 2002 and 2008 by the first author (CES) were retrospectively reviewed. Results: A total of 88 patients with 100 aneurysms of the anterior circulation were treated in a six years period. Fifty eight female (66%) and thirty male (34%) with nine patients (10.2%) presenting with multiple aneurysms. The mean age was 52 years (range from 26 to 76 years). Eighty five percent of the cases were ruptured aneurysms. The mean follow-up was 52.4 months (range from 5 to 76 months). The topography of the aneurysms was distributed as it follows: Anterior communicating artery (ACoA) 25%; posterior communicating artery (p-comm) 29%; middle cerebral artery (MCA) 27%; paraclinoidal aneurysms 8%; pericallosal artery 6% and internal carotid artery (ICA) tip 5%. The mortality was 7.9%, and such cases presenting with Hunt Hess graduation 3 and 4. The permanent morbidity was 4.5%, cases with Hunt Hess graduation 3 and 4. Perioperative rupture occurred in 17% of the cases, only in previous ruptured aneurysms. There was no clinical evidence of rebleeding during the follow-up period of the series. Conclusions: The microsurgical clipping of cerebral aneurysms of the anterior circulation is a safe and curative treatment for most of such lesions. At present, studies suggest evidences of superior results of surgery compared to the endovascular techniques in the rates of total occlusion of the aneurysms, lesser rates of rebleeding of the treated cases. The results of the present series are similar to the rates of the most relevant literature.

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In-Stent Thrombosis and Stenosis After Neck-Remodeling Device-Assisted Coil Embolization of Intracranial Aneurysms

Neurosurgery ◽

10.1227/neu.0b013e3181f8d194 ◽

2010 ◽

Vol 67 (6) ◽

pp. 1523-1533 ◽

Cited By ~ 44

Author(s):

Hilal Kanaan ◽

Brian Jankowitz ◽

Aitziber Aleu ◽

Dean Kostov ◽

Ridwan Lin ◽

...

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Anterior Communicating Artery ◽

Complication Rates ◽

Stent Patency ◽

Unruptured Aneurysms ◽

Short And Long Term ◽

Stent Complications

Abstract BACKGROUND: Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling devices in the treatment of intracranial aneurysms. OBJECTIVE: To examine the technical and anatomic factors that predict short- and long-term stent patency. METHODS: We undertook a retrospective review of 161 patients who underwent coil embolization of 168 ruptured and unruptured aneurysms assisted by the use of a neck-remodeling device. One hundred twenty-seven patients had catheter-based angiographic follow-up to evaluate 133 stent-coil constructs (mean, 15.4 months; median, 12.7 months). The technique of microcatheter jailing was used in a majority of patients; nonstandard stent configurations were also used. RESULTS: Clinical follow-up for all patients who had catheter-based angiograms demonstrated that among 133 stent constructs, a total of 9 (6.8%) had an in-stent event: 6 acute or subacute thrombosis (4.5%) and 3 delayed stenosis or occlusion (2.3%). Seven of these constructs were associated with a symptomatic event (5.3%). A significantly higher rate of in-stent events was seen with the use of constructs to treat anterior communicating artery aneurysms. When all patients are considered, including those who did not receive catheter-based follow-up imaging, 2 of 168 procedures (1.2%) resulted in the death of a patient, and procedural morbidity was 14.9%. CONCLUSION: From these results and those in the published literature, in-stent complication rates are low in carefully selected patients. The use of dual antiplatelet therapy, sensitivity assays, and glycoprotein IIb/IIIa inhibitors may decrease the rate of acute and chronic in-stent complications.

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Early and late results of intracranial direct surgery of anterior communicating artery aneurysms

Journal of Neurosurgery ◽

10.3171/jns.1979.50.4.0433 ◽

1979 ◽

Vol 50 (4) ◽

pp. 433-440 ◽

Cited By ~ 30

Author(s):

Shigeaki Hori ◽

Jiro Suzuki

Keyword(s):

Operative Mortality ◽

Artery Aneurysm ◽

Late Results ◽

Anterior Communicating Artery ◽

Content Type ◽

Mortality And Morbidity ◽

Unruptured Aneurysms ◽

Accurate Treatment ◽

Intracranial Operation

✓ During the 14-year period up to September, 1975, 346 patients with a single anterior communicating artery aneurysm, including eight with unruptured aneurysms, were operated on by direct intracranial procedures. There was an early operative mortality of 5.5%. Follow-up studies, an average of 3 years 11 months after surgery, revealed that about 85% of the survivors, excluding those who could not be followed, had regained their working capacity, and that the late mortality and morbidity rates were 9.6% and 2.0%, respectively. The rationale for performing the intracranial operation and factors influencing postoperative results are discussed, with particular emphasis on the techniques for accurate treatment of aneurysms that help to prevent postoperative rebleeding and therefore give better overall surgical results.

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