Endovascular Management of Anterior Communicating Artery Aneurysms

Clipping of a Ruptured Small Anterior Communicating Artery Aneurysm: Technical Video

In recent years there has been a significant shift in the management of intracranial aneurysms, as most, both ruptured and unruptured, are being treated through an endovascular approach.1-3 However, there are still instances in which open surgical clipping is the best option for definitive management. Both patient factors, such as age and comorbidities, and aneurysm characteristics, such as size, morphology, and location, must be taken into consideration when treating aneurysms. This is especially true for anterior1 communicating artery aneurysms, as these have been treated successfully using multiple different techniques.4,5 There are no absolute guidelines indicating how a particular aneurysm should be treated and, therefore, one must be able to determine how to best manage a patient based on their own skill set, knowledge, and experience. We present a case of a 61-year-old woman who presented with a ruptured anterior communicating artery aneurysm. Initially she was brought to the angiography suite to undergo possible endovascular treatment of the aneurysm, but after reviewing the morphology and size of the aneurysm, we believed that this aneurysm could not be treated safely through an endovascular approach and surgical clipping was the better option. The patient consented to the procedure. In this operative video, we describe the technical aspects of the surgical procedure and the benefits of our approach (Video 1).

Intraoperative Aneurysm Rupture During Microsurgical Clipping: Risk Re-evaluation in the Post-International Subarachnoid Aneurysm Trial Era

OBJECTIVES

Intraoperative aneurysm rupture (IOAR) is a common complication during intracranial aneurysm (IA) surgery. In light of the paradigm shift regarding IA selected for clipping in the post-International Subarachnoid Aneurysm Trial (ISAT) era, we aimed to evaluate the risk factors and effects of IOAR in an institutional series of clipped ruptured IA (RIA) and unruptured IA (UIA).

MATERIAL AND METHODS

All IAs treated with microsurgical clipping at our institution between 2003 and 2016 were eligible for this study. Demographic, clinical, and radiographic factors were correlated with occurrence of IOAR in univariate and multivariate analyses. The effect on outcome was analyzed for RIA and UIA separately.

RESULTS

Nine hundred and three clipped IAs were included in the final analysis (538 UIA and 365 RIA). IOAR occurred in 163 cases (18.1%), mostly during clipping of RIA (37.5% vs. 4.8%) In multivariate analysis, ruptured status (adjusted odds ratio [aOR], 10.46; P < 0.001), sack size (aOR, 1.05 per mm increase; P = 0.038) and IA location in the anterior communicating artery (aOR, 2.31; P < 0.001) independently predicted IOAR. For RIA cases, IOAR was also independently predicted by rebleeding before therapy (aOR, 3.11; P = 0.033) and clinical severity of subarachnoid hemorrhage (aOR, 1.18 per WFNS grade increase; P = 0.049). IOAR independently predicted poor outcome (aOR, 1.83; P = 0.042) after RIA surgery. In turn, IOAR affected only the risk for cerebral infarct (OR, 3.75; P = 0.003) and incomplete IA occlusion (OR, 3.45; P = 0.003) for UIA cases, but not the outcome (P = 0.263).

CONCLUSIONS

IOAR was independently predicted by the ruptured status, location, and size of IA and by initial severity of aneurysmal bleeding and pretreatment rebleeding. The influence of IOAR differed between RIA and UIA cases.