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

Neuropsychological outcomes in patients with ruptured anterior communicating artery aneurysms treated by clipping versus coiling: a systematic review and meta-analysis

Ruptured anterior communicating artery (ACoA) aneurysms are frequently associated with neuropsychological deficits. This review aims to compare neuropsychological outcomes between surgical and endovascular approaches to ACoA. We systematically searched PubMed, Embase, and Web of Science for studies comparing the endovascular and surgical approaches to ruptured ACoA aneurysms. Outcomes of interest were the cognitive function, covered by memory, attention, intelligence, executive, and language domains, as well as motor and visual functions. Nine studies, comprising 524 patients were included. Endovascularly-treated patients showed better memory than those treated surgically (Standardized Mean Difference (SMD) = -2; 95% CI: -3.40 to -0.61; p < 0.01). Surgically clipped patients had poorer motor ability than those with coiling embolization (p = 0.01). Executive function (SMD = -0.20; 95% CI: -0.47 to 0.88; p = 0.55), language (SMD = -0.33; 95% CI: -0.95 to 0.30; p = 0.30), visuospatial function (SMD = -1.12; 95% CI: -2.79 to 0.56; p = 0.19), attention (SMD = -0.94; 95% CI: -2.79to 0.91; p = 0.32), intelligence (SMD = -0.25; 95% CI: -0.73 to 0.22; p = 0.30), and self-reported cognitive status (SMD = -0.51; 95% CI: -1.38 to 0.35; p = 0.25) revealed parity between groups. Patients with ACoA treated endovascularly had superior memory and motor abilities. Other cognitive domains, including executive function, language, visuospatial function, attention, intelligence and self-reported cognitive status revealed no statistically significant differences between the two approaches. Trial Registration PROSPERO (International Prospective Register of Systematic Reviews) CRD42023461283; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=461283.

A Right-Sided Approach to Anterior Communicating Artery Aneurysms: A Case Review and Technical Report

Anterior communicating artery (ACoA) aneurysms are the most frequently encountered type of intracranial aneurysm. ACoA aneurysms may require treatment depending on clinical presentation, size, risk of rupture, and ruptured status. In patients where treatment is indicated, options entail endovascular securement or clipping. Under the clipping umbrella, surgical approaches traditionally entail a pterional craniotomy and its modifications such as the lateral supraorbital approach. Sidedness of this craniotomy has been a topic of debate. To discuss this we present a case and technical report with nuances of the approach wherein a 48-year-old female presented with the worst headache of her life. The patient was found to have a ruptured wide-necked 7.2 x 8.1 x 5.8 mm ACoA aneurysm more eccentric to the left and fed from the left A1 intertwined with a frontopolar branch, numerous perforators and the recurrent artery of Heubner. The patient underwent a successful clipping from a right-sided approach. As such, with appropriate skull base drilling, exposure, optimization of brain relaxation, and a generous opening of the Sylvian fissure bilateral internal carotid arteries, anterior cerebral arteries with both A1 and A2 segments, middle cerebral arteries, the ACoA, and the relevant anatomy can be appropriately visualized from a right-sided approach. Therefore, an approach is described to optimize exposure to allow for nearly all anterior communicating aneurysms to be clipped from a right-sided pterional approach.

Microsurgical Clip Suspension to Prevent Optic Neuropathy Following Ligation of Anterior Communicating Artery Aneurysm: A Technical Report and Surgical Video

Anterior communicating artery (ACoA) aneurysms are among the most common intracerebral aneurysms. Complications of ACoA aneurysm include subarachnoid hemorrhage, which may occur spontaneously or as a result of trauma. While prognosis of microsurgical clip ligation is excellent, iatrogenic afferent pupillary defect secondary to mechanical compression of the optic nerve by the clips is a known complication. Our report presents a case of a 59-year-old female status post resection of a pituitary macroadenoma one year ago with a three- to four-week history of progressively worsening headache found to have a 6.5 x 5.4 mm wide neck and irregularly dysplastic aneurysmal dilation of the ACoA. During the operation, two of the longer clips appeared to be touching the optic nerve and we utilized a clip suspension technique to relieve compression. This gently elevated and suspended the two clips up to the dura, allowing for a 2 mm gap between the optic nerve and clips. This maneuver relieved mechanical compression against the optic nerve and potentially mitigated the need for surgical re-exploration in the future.