Development of a comprehensive and clinically applicable novel projection classification system for anterior communicating artery aneurysms

Abstract

Various surgical and anatomical classifications have been proposed to date related to ACoA aneurysm projection. Nonetheless, a universally accepted classification system is yet to be established. This study is aimed at establishing a standardized classification system for ACoA aneurysms with utilization 3D technology and defining reference lines for their projections. The goal is to create a simple, understandable, surgically beneficial, and reliable classification system based on neurovascular structures in the region, including safe and hazardous zones. The radiologic data of 96 patients with ACoA aneurysm who were treated in our university hospital between 2012 and 2020 were retrospectively analyzed, and a planned classification scale was developed with the data obtained. The classification aimed to create 9 main projection groups in the sagittal plane: superior, inferior, anterior, and posterior in linear orientation, and anterosuperior, posterosuperior, anteroinferior, posteroinferior, and complex in quadrant orientation. The coronal and axial planes included medial, lateral, and midline classifications, resulting in a 3-dimensional classification system with 25 projections. Among the 96 patients, 32 had linear and 64 had quadrant projections. In the sagittal plane, the linear projection breakdown was as follows: superior (28%), inferior (6.25%), anterior (53%), and posterior (12.5%). For the quadrant projection, the distribution was as follows: anterosuperior (53%), posterosuperior (12.5%), anteroinferior (21.87%), posteroinferior (3.12%), and complex (9.37%). Overall, 35.4% aneurysms were anterosuperior, 17.7% anterior, 14.58% anteroinferior, 9.37% superior, 8.3% posterosuperior, 6.25% complex, 4.16% posterior, 2.08% posteroinferior, and 2.08% inferior projection. Our study proposes a projection classification that utilizes 3D technology for safe surgery based on neurovascular structures in the region and thus better reveals safe and hazardous zones, including three plans, three dimensions, and two orientations. The use of this classification system offers valuable guidance for daily practice in the treatment of ACoA aneurysms.