Artery Acom Research Articles

Anterior Communicating Artery Aneurysms: Surgical Strategy and Outcome based on Proposed Newer Classification

Background: The ruptured anterior communicating artery aneurysm is the most frequent intra-cranial aneurysm treated at any neurosurgical department. These aneurysms arise from either the A1-A2-Acom artery junction or Acom artery. The surgical outcome depends on the age of the patient, time duration between ictus and surgery, and Hunt and Hess grade at admission. In this article, we intend to analyze the surgical outcome based on our proposed classification with our overall experience of Acom aneurysm. Methods: A retrospective review of our surgical database with 250 patients of ruptured Acom was done, and the location, morphology, and direction of aneurysm, along with other clinical parameters including the demographic profile, radiological findings, and intra-operative details, were studied. We classified the Acom based on both site of origin and morphology (Type I, junctional on the dominant side; Type II, fusiform with an ill-defined neck and branching pattern; Type III, saccular true Acom A) and secondarily as described in the literature on the basis of the direction of fundus (Type A–E). The clinical parameters were compared among the above groups using Fischer-exact and one-way analysis of variance test. Results: A total of 250 patients (M: F =113:137) were included (mean age 52.1 ± 11.5 standard deviation years). 55.2% patients had left A1 dominance. Type I Acom A was commonly found on the left dominant circulation (P = 0.00). The difference in aspect ratio of Type I (2.0 ± 0.8) and Type II (1.8 ± 0.52) aneurysms was insignificant (P = 0.28). However, a significant difference in post-operative vasospasm among different types of aneurysms was found (P < 0.05). The Type I Acom A were anteriorly directed, while Type II and III were posteriorly directed (P = 0.001). The mean follow-up of the study was 44.4 ± 25.7 months, with age (P = 0.007) and Hunt and Hess grade (P = 0.001) at admission correlating with surgical outcome. Conclusion: Classifying the Acom A pre-operatively based on site and morphology, location, and direction of fundus helps in surgical planning and prognosis. The junctional ‘Type IA aneurysms’ are most common and possess a high intra-operative rupture rate. The anteriorly directed aneurysms have a better prognosis, and visual complaints are usually associated with anterior-inferiorly directed aneurysms.

Correlation Between Aneurysm Dome Direction and Patient Outcomes Following Surgery for Ruptured Anterior Communicating Artery Aneurysms.

Background Anterior communicating (Acom) artery aneurysms are the most common type of intracranial aneurysms. Despite the enormous advancements in the field of endovascular surgery for intracranial aneurysms, open surgical clipping of aneurysms remains the most durable management of Acom aneurysms. There have been various studies based on the clinical-radiological profile and outcome of open clipping for intracranial aneurysms, but the correlation of the direction of the aneurysm with the surgical outcome remains incompletely defined. Aim To analyze the correlation between the direction of the aneurysm dome and patient outcomes after surgery for ruptured Acom artery aneurysms. Materials and methods CT angiography of the brain was done in all patients pre-operatively as part of the standard treatment protocol. Retrospective data was collected from an inter-departmental computerized database, which included the patient's details, history, investigations, a course in the hospital from admission to discharge, and an operative note by the surgeon. Prospective data was collected from patients with ruptured Acom artery aneurysms. We analyzed the relationship between the direction of the dome of the Acom aneurysm and preoperative, intraoperative, and postoperative variables. Results Of the 48 patients who underwent surgery for ruptured aneurysms, 34 (70.8%) were female and 14 (29.2%) were male. Among the 27 cases with anteriorly projecting aneurysms, 11 (40.7%) experienced postoperative complications. Of the five cases with posteriorly projecting aneurysms, two (40%) experienced postoperative complications. One-third of cases of the inferior dome direction and 10% of cases of the superior direction of the dome of aneurysm were also found to have postoperative complications. However, using the chi-square test, the association between postoperative complications and the direction of the aneurysm was determined to be statistically non-significant (p-value = 0.93). Conclusion The findings of our investigation indicate that aneurysms with superior projection exhibit the lowest likelihood of experiencing intraoperative rupture. However, it was seen that the outcome was influenced by dome projection throughout the three-month follow-up. The findings of our study indicate that aneurysms with a superior orientation exhibit the least likelihood of experiencing intraoperative rupture.

A Rare Case of Four Aneurysms Arising from Anterior Communicating Artery: Diagnostic Dilemma and Surgical Difficulties

ABSTRACT Multiple aneurysms of the anterior communicating artery in a single patient occur rarely. The authors report a case of four aneurysms arising from Acom artery in a single patient, which is the highest number reported so far. Treatment for such aneurysms either by clipping or coiling, needs to be individualized. The radiological and surgical difficulties encountered intreating these complex and uncommon aneurysms are discussed.

The supraorbital keyhole approach for clipping of anterior circulation ruptured aneurysms

Introduction. The supraorbital approach has been demonstrated to be useful, particularly in minimization of brain retraction and exposure to air, decreases blood loss, surgical trauma, operative time and infection rates. While its shortcomings include difficult control of frontal air sinus, narrower surgical view and limited exposure of sylvian fissure.
 Patients and methods. We retrospectively reviewed the files of patients who underwent clipping of anterior circulation aneurysms through the supraorbital keyhole approach at Neurosurgery Department, Mansoura University between Jan 2014 and May 2016.
 Results. Twenty-five consecutive patients harbouring aneurysm at anterior circulation underwent clipping through the supraorbital keyhole approach, sixteen A-com artery aneurysms and nine cases of ICA aneurysms Table 1 show the location of aneurysms. Eleven patients were males, and 14 were females. The ages ranged from 44 to 69 with a mean age of 61.9 years. All patients were presented with subarachnoid haemorrhage due to rupture of aneurysms in anterior circulation The Hunt and Hess grade was (1.50 ± 0.65) and Fisher grade was (1.67 ± 0.45). The average operative time was 3.32 ± 1.14 hours. Follow-up ranged from 1 to 16 months with a mean of 7 months
 Conclusion. Surgical clipping of some selected aneurysms of anterior circulation can be operated through minimally invasive supraorbital approach which minimize the dissection and retraction of the brain, reduce operative time and blood loss with small incision and good cosmetic results.

Are Anterior Communicating Aneurysms Truly Anterior Communicating Aneurysms? An Observational Study

The term anterior communicating (ACom) aneurysm is often broadly used to classify any aneurysm formed on the A1-A2 junction, A1, A2, or ACom arteries. Aneurysm location has been associated with rupture risk, so whether an aneurysm is truly formed on the ACom artery can critically affect treatment decisions. The aim of this study was to reclassify broadly termed ACom aneurysms into 4 subgroups (A1, A2, true ACom, and A1-A2 junction) based on their location. A retrospective, pilot study was conducted to identify all consecutive patients with ACom aneurysm managed over the past 4 years in a single center. Using computed tomography angiography, aneurysms were classified into 1 of the 4 subgroups. Additional information was collected on patient demographics, subarachnoid hemorrhages, projections of aneurysm dome, and aneurysm diameter. A total of 48 aneurysms with available computed tomography angiography imaging were included in the final analysis. The reclassification of ACom aneurysms into subgroups resulted in 40 A1-A2 junction, 6 true ACom, 2 A2, and zero A1 aneurysms. A total of 100% versus 80% of true ACom and A1-A2 junction aneurysms ruptured, respectively. All elective coiling procedures were performed on unruptured A1-A2 junction aneurysms. We found only 13% of the aneurysms initially referred to as ACom to be true ACom aneurysms. A more nuanced approach to ACom aneurysm classification may better guide management strategies.

Coincidence of Anterior Communicating Artery Aneurysm in a Patient With Carotid Body Tumor: A Case Report

Background: Intracranial aneurysms (IAs) are focal pathologic dilation of cerebral vasculature, which mostly affect the anterior circulation of brain. Carotid body tumors (CBTs) are the most common head and neck parasympathetic paragangliomas. These slow growing neoplasms may cause hypertension along with catecholamine release symptoms, mostly in patients in their fourth decade. This is the second reported case of simultaneous presentation of CBT and IA in a male patient.Case Presentation: A 54-year-old male with positive history of hypertension presented with isolated acute weakness of right upper extremity. Bilateral Doppler ultrasound of carotid arteries showed a mass at left carotid bifurcation, which was confirmed by vessels computed tomography (CT) – angiography. CT scan also demonstrated anterior communicating artery (A-Com) aneurysm. Digital subtraction angiography (DSA) confirmed a right sided A-com artery aneurysm. Aneurismal repair was performed prior to CBT removal.Conclusion: Although multifactorial etiologies, such as hypertension, atherosclerosis and congenital predisposition with vascular abnormalities exists; this case raises the possibility of etiologic relationship between hypertension and hypertensive crises due to catecholamine release and aneurismal development and rupture. Avoidance of possible life threatening complications of aneurismal rupture necessitates preoperative evaluation for CBT in patients with established diagnosis of IA.

Abstract W P79: Hyperhomocysteinemia Is Associated With Vulnerability of the Cerebral Aneurysmal Wall to Rupture in Ovariectomized Rats

Introduction: The pathogenesis of cerebral aneurysms is multifactorial. Hyperhomocysteinemia (HHcy) leads to endothelial and platelet deterioration and may be associated with the formation of cerebral aneurysms. We tested the hypothesis that HHcy plays a role in the growth and/or rupture of cerebral aneurysms. Methods: We exposed 13-week-old female Sprague-Dawley rats fed a high-salt diet to estrogen deficiency, hemodynamic stress, and induced hypertension. To induce HHcy we added methionine to their drinking water. Results: In methionine induced rats the aneurysms the total rupture rate was higher than in rats not treated with methionine. One fourth of the aneurysms arising at the anterior communicating (Acom) artery, and half of the aneurysms at the posterior half of the circle of Willis, but no aneurysms at the anterior cerebral artery-olfactory artery (ACA-OA) bifurcation ruptured. Immunohistochemically, the infiltration of M1 macrophages was increased at the Acom artery in methionine induced rats and the messenger ribonucleic acid level of matrix metalloproteinase (MMP)-9, the ratio of MMP-9 to tissue inhibitor of metalloprotease (TIMP)2, and the interleukin-6 level were higher at the Acom artery than the ACA-OA bifurcation. Treatment with folic acid abolished the exacerbated effects due to HHcy, suggesting that the propensity of cerebral aneurysms at the Acom artery to rupture is attributable to disequilibrium between the degradation molecules and their inhibitors and to macrophage infiltration. Conclusion: HHcy may be associated with vulnerability of the cerebral aneurysmal wall to rupture in hypertensive ovariectomized rats.

E-023 Consecutive Endovascular Treatment of Ruptured Very Small (

BackgroundThe anterior communicating (ACom) artery is the most common location of cerebral aneurysms harbouring upto 30–37% of all treated aneurysms. Amongst all ruptured aneurysms, the proportion of patients with very...

The Efficacy of Simultaneous Bilateral Internal Carotid Angiography during Coil Embolization for Anterior Communicating Artery Aneurysms

Successful coil embolization of anterior communicating (A-com) artery aneurysms requires good visualization and understanding of the entire H complex. Bilateral carotid angiography may optimize anatomical understanding and visualization of the H complex. We therefore assessed the efficacy of simultaneous bilateral internal carotid angiography during coil embolization for A-com artery aneurysms. Of the 153 patients with intracranial saccular aneurysms who underwent embolization between July 2008 and December 2009, 12 had A-com artery aneurysms and were embolized under bilateral carotid angiography. Patients were evaluated angiographically, immediately and 6 months (n=11) after embolization, using a 3-point scale (complete, residual neck, residual aneurysm). The safety, performance and efficacy of this approach were retrospectively evaluated. In all patients, bilateral internal carotid artery angiography provided more detailed anatomical information and understanding around the A-com artery, and, in complex situations, it allowed for more effective coil embolization through bilateral routes to the A-com artery. Angiography immediately after embolization showed occlusion of 11 of the 12 (92%) aneurysms, with none of these 11 showing evidence of recanalization at 6 months. These findings indicate that simultaneous bilateral carotid angiography during coil embolization of selected complex A-com artery aneurysms provided improved anatomical understanding, and resulted in more effective and safer procedures than typical unilateral angiography.