Impact of Postoperative Infarcts in Determining Outcome after Clipping of Anterior Communicating Artery Aneurysms

The risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms: anatomical consideration and infarction territory

PURPOSE

An anterior communicating artery is a common location for both ruptured and unruptured intracranial aneurysms, and microsurgery is sometimes necessary for their successful treatment. However, postoperative infarction should be considered during clipping due to the complex surrounding structures of anterior communicating artery aneurysms. This study aimed to evaluate the risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms and its clinical outcomes.

METHODS

The data of patients who underwent microsurgical clipping of an unruptured anterior communicating artery aneurysm in our hospital between January 2008 and December 2020 were retrospectively analyzed. The patients' demographic data, anatomical features of the anterior communicating artery complex and aneurysm, surgical technique, characteristics of postoperative infarction, and its clinical course were evaluated.

RESULTS

Notably, among 848 patients, 66 (7.8%) and 34 (4%) patients had radiologic and symptomatic infarctions, respectively. Univariate and multivariate logistic regression analyses showed that hypertension (odds ratio (OR), 1.99; [Formula: see text]), previous stroke (OR, 3.89; [Formula: see text]), posterior projection (OR, 5.58; [Formula: see text]), aneurysm size (OR, 1.17; optimal cut-off value, 6.14 mm; [Formula: see text]), and skull base-to-aneurysm distance (OR, 1.15; optimal cut-off value, 11.09 mm; [Formula: see text]) were associated with postoperative infarction. In the pterional approach, a closed A2 plane was an additional risk factor (OR, 1.88; [Formula: see text]). Infarction of the subcallosal and hypothalamic branches was significantly associated with symptomatic infarction ([Formula: see text]).

CONCLUSION

Hypertension, previous stroke, posteriorly projecting aneurysms, aneurysm size, and highly positioned aneurysms are independent risk factors for postoperative infarction during surgical clipping of an unruptured anterior communicating artery aneurysm. Additionally, a closed A2 plane is an additional risk factor of postoperative infarction in patients undergoing clipping via the pterional approach.

Mechanical clot dissolution technique for surgical clip-related occlusions: An emergent triple-step approach

Cerebral ischemia following clipping of cerebral aneurysms constitutes major cause of morbidity and mortality. Clip-related injury to vessel, postoperative clip rotation, prolonged temporary occlusion, intraoperative rupture, and vasospasm are some etiological factors compromising forward flow in parent or branch vessel. On suspicion of compromised forward flow, immediate intraoperative evaluation is done to detect the cause of vascular compromise and further management is done by microsurgical or endovascular means. We describe a case of ruptured distal anterior cerebral artery (ACA) aneurysm complicated by occlusion of ACA after surgical clipping. The patient was managed by endovascular means by combined technique of intra-arterial nimodipine, antiplatelet infusion, and mechanical clot disruption using J-tip microwire.