Anterior Communicating Artery Research Articles

The safety and clinical outcomes of endovascular treatment versus microsurgical clipping of ruptured anterior communicating artery aneurysms: a 2-year follow-up, multicenter, observational study

Background and objectiveCurrent data on the optimal treatment modality for ruptured anterior communicating artery (AComA) aneurysms are limited. We conducted this multicenter retrospective study to evaluate the safety and clinical outcomes of endovascular treatment (EVT) and microsurgical clipping (MC) for the treatment of ruptured AComA patients.MethodsPatients with ruptured AComA aneurysms were screened from the Chinese Multicenter Cerebral Aneurysm Database. Propensity score matching (PSM) was used to adjust for baseline characteristic imbalances between the EVT and MC groups. The safety outcomes included total procedural complications, procedure-related morbidity/death and remedial procedure for complication. The primary clinical outcome was 2-year functional independence measured by the modified Rankin scale (mRS) score.ResultsThe analysis included 893 patients with ruptured AComA aneurysms (EVT: 549; MC: 346). PSM yielded 275 pairs of patients in the EVT and MC cohorts for comparison. Decompressive craniectomy being more prevalent in the MC group (19.3% vs. 1.5%, p < 0.001). Safety data revealed a lower rate of total procedural complications (odds ratio [OR] = 0.62, 95% CI 0.39–0.99; p = 0.044) in the EVT group and similar rates of procedure-related morbidity/death (OR = 0.91, 95% CI 0.48–1.73; p = 0.880) and remedial procedure for complication (OR = 1.35, 95% CI 0.51–3.69, p = 0.657) between the groups. Compared with that of MC patients, EVT patients had a greater likelihood of functional independence (mRS score 0–2) at discharge (OR = 1.68, 95% CI 1.14–2.50; p = 0.008) and at 2 years (OR = 1.89, 95% CI 1.20–3.00; p = 0.005), a lower incidence of 2-year all-cause mortality (OR = 0.54, 95% CI 0.31–0.93; p = 0.023) and a similar rate of retreatment (OR = 1.00, 95% CI 0.23–4.40; p = 1.000).ConclusionClinical outcomes after treatment for ruptured AComA aneurysms appear to be superior to those after treatment with MC, with fewer overall procedure-related complications and no increase in the retreatment rate. Additional studies in other countries are needed to verify these findings.

Successive Development and Rupture of Blister-Like Anterior Communicating Artery Aneurysms at Mirror Locations.

This is the first report of the successive development and rupture of blister-like anterior communicating artery (ACoA) aneurysms at mirror locations with a short interval. A 49-year-old man presented with an angiogram-negative subarachnoid hemorrhage with significant basal frontal interhemispheric blood. Surgical exploration revealed a blister-like aneurysm on the left side of the superior wall of the ACoA, which was treated using a microsuturing technique. On the 18th day after the initial subarachnoid hemorrhage, the second operation due to another angiogram-negative hemorrhage revealed a de novo blister-like aneurysm with a small blood clot on the posterosuperior wall of the ACoA close to the right A1/A2 junction. The rupture point and ACoA on the right side were occluded using an aneurysm clip. Follow-up digital subtraction angiogram (DSA) at 4 years and computed tomography angiogram (CTA) at 14 years after the surgery showed no recurrence or associated abnormality.

Quantitative Analysis of the Supraorbital, Transorbital Microscopic, and Transorbital Neuroendoscopic Approaches to the Anterior Skull Base and Paramedian Vasculature

Abstract Objectives Our objective was to compare transorbital neuroendoscopic surgery (TONES) with open craniotomy and analyze the effect of visualization technology on surgical freedom. Design Anatomic dissections included supraorbital craniotomy (SOC), transorbital microscopic surgery (TMS), and TONES. Setting The study was performed in a neurosurgical anatomy laboratory. Participants Neurosurgeons dissecting cadaveric specimens were included in the study. Main Outcome Measures Morphometric analysis of cranial nerve (CN) accessible lengths, frontal lobe base area of exposure, and craniocaudal and mediolateral angle of attack and volume of surgical freedom (VSF) of the paraclinoid internal carotid artery (ICA), terminal ICA, and anterior communicating artery (ACoA). Results The mean (standard deviation [SD]) frontal lobe base parenchymal exposures for SOC, TMS, and TONES were 955.4 (261.7) mm2, 846.2 (249.9) mm2, and 944.7 (158.8) mm2, respectively. Access to distal vasculature was hindered when using TMS and TONES. Multivariate analysis estimated that accessing the paraclinoid ICA with SOC would provide an 11.2- mm3 increase in normalized volume (NV) compared with transorbital corridors (p < 0.001). There was no difference between the three approaches for ipsilateral terminal ICA VSF (p = 0.71). Compared with TONES, TMS provided more access to the terminal ICA. For the ACoA, SOC produced the greatest access corridor maneuverability (mean [SD] NV: 15.6 [5.6] mm3 for SOC, 13.7 [4.4] mm3 for TMS, and 7.2 [3.5] mm3 for TONES; p = 0.01). Conclusion SOC provides superior surgical freedom for targets that require more lateral maneuverability, but the transorbital corridor is an option for accessing the frontal lobe base and terminal ICA. Instrument freedom differs quantifiably between the microscope and endoscope. A combined visualization strategy is optimal for the transorbital corridor.

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.

Analysis of the impact of intraventricular hemorrhage on the functional outcome of ruptured anterior cerebral artery aneurysm after clipping.

Various clinical symptoms and variables have been suggested as potential indicators of outcomes in patients with subarachnoid hemorrhage (SAH) resulting from ruptured intracranial aneurysms. The detailed discussion of the consequences of intraventricular hemorrhage (IVH), frequently reported in cases of anterior communicating artery (ACoA) aneurysms, is still pending. The study aimed to assess the results of aneurysm surgery performed early versus delayed in patients with SAH, specifically focusing on the occurrence of IVH. This study involved patients with ACoA aneurysms who experienced SAH and underwent microsurgical clipping of the aneurysm. A retrospective review was conducted on the patients' medical records. The modified Rankin score was compared between two groups of patients based on the presence or absence of IVH. Ninety-one participants (52 males and 39 females) were included in the study. The initial computed tomography scan showed that 20 patients (with a mean age of 51 ± 13.7 years) had IVH, while 71 patients (with a mean age of 45.8 ± 11.7 years) did not have any signs of IVH. The proportion of patients with poor functional outcomes after six months was 55% in the presence of IVH, compared to 25.4% in patients without IVH, indicating a significant difference in outcome between the two groups (P < 0.016). Patients with SAH having aneurysms located in the ACoA associated with the intraventricular hemorrhage had a poor functional outcome.

The biportal transorbital approach: quantitative comparison of the anterior subfrontal craniotomy, bilateral transorbital endoscopic, and microscopic approaches.

The aim of this study was to assess the surgical use and applicability of a biportal bitransorbital approach. Single-portal transorbital and combined transorbital transnasal approaches have been used in clinical practice, but no study has assessed the surgical use and applicability of a biportal bitransorbital approach. Ten cadaver specimens underwent midline anterior subfrontal (ASub), bilateral transorbital microsurgery (bTMS), and bilateral transorbital neuroendoscopic surgery (bTONES) approaches. Morphometric analyses included the length of the bilateral cranial nerves I and II, the optic tract, and A1; the area of exposure of the anterior cranial fossa floor; craniocaudal and mediolateral angles of attack (AOAs); and volume of surgical freedom (VSF; maximal available working volume for a specific surgical corridor and surgical target structure normalized to a height of 10 mm) of the bilateral paraclinoid internal carotid arteries (ICAs), bilateral terminal ICAs, and anterior communicating artery (ACoA). Analyses were conducted to determine whether the biportal approach was associated with greater instrument freedom. The bTMS and bTONES approaches provided limited access to the bilateral A1 segments and the ACoA, which were inaccessible in 30% (bTMS) and 60% (bTONES) of exposures. The average total frontal lobe area of exposure (AOE) was 1648.4 mm2 (range 1516.6-1958.8 mm2) for ASub, 1658.9 mm2 (1274.6-1988.2 mm2) for bTMS, and 1914.9 mm2 (1834.2-2014.2 mm2) for bTONES exposures, with no statistically significant superiority between any of the 3 approaches (p = 0.28). The bTMS and bTONES approaches were significantly associated with decreases of 8.7 mm3 normalized volume (p = 0.005) and 14.3 mm3 normalized volume (p < 0.001) for VSF of the right paraclinoid ICA compared with the ASub approach. No statistically significant difference in surgical freedom was noted between all 3 approaches when targeting the bilateral terminal ICA. The bTONES approach was significantly associated with a decrease of 105% in the (log) VSF of the ACoA compared with the ASub (p = 0.009). Although the biportal approach is intended to improve maneuverability within these minimally invasive approaches, these results illustrate the pertinent issue of surgical corridor crowding and the importance of surgical trajectory planning. A biportal transorbital approach provides improved visualization but does not improve surgical freedom. Furthermore, although it affords impressive anterior cranial fossa AOE, it is unsuitable for addressing midline lesions because the preserved orbital rim restricts lateral movement. Further comparative studies will elucidate whether a combined transorbital transnasal route is preferable to minimize skull base destruction and maximize instrument access.

Intraoperative Complications in Cerebral Endovascular Aneurysmal Surgery: A Retrospective Single-Center Study (2019-2023)

BACKGROUND: Endovascular cerebral aneurysm surgery, also known as endovascular neurosurgery, represents a minimally invasive approach aimed at diagnosing and treating intracerebral aneurysms through the use of catheters, wires, and various specialized instruments. This innovative approach has emerged as a promising alternative to traditional open surgical methods for addressing cerebral aneurysms. However, it is essential to acknowledge that while endovascular procedures offer numerous advantages, such as reduced morbidity and mortality rates, they are not devoid of associated risks, some of which can have life-threatening consequences. This paper seeks to delve into the realm of intraoperative complications in patients undergoing endovascular treatment for aneurysms, shedding light on the challenges and complexities within this field. METHODS: For this retrospective investigation, we conducted a comprehensive analysis of medical records spanning a five-year period, from 2019 to 2023. These records were obtained from the Neurosurgical Clinic of Belgrade, located within the University Clinical Center of Serbia. The study cohort comprised 44 patients who encountered intraoperative complications during endovascular aneurysm treatment. Patient information, including age, gender, aneurysm size, location, specific segment, and details regarding the nature of the intraoperative complications, was meticulously collected. Subsequently, the gathered data underwent rigorous statistical analysis. RESULTS: Out of a total of 429 patients who underwent endovascular treatment for aneurysms, 44 experienced intraoperative complications. The average age of these individuals was 55.4 years, ranging from 13 to 83 years, with the majority being women (37 out of 44, or 84.1%). Thirteen patients (29.5%) presented with significant preoperative co-morbidities and had previously experienced subarachnoid hemorrhaging before undergoing treatment. The most prevalent location for aneurysms was the internal carotid artery (ICA), accounting for 40.9% of cases, with the C6 segment being the most frequently affected at 27.3%. Other notable locations included the anterior communicating artery (ACoA) at 34.1% and the middle cerebral artery (MCA) at 13.6%. Regarding intraoperative complications, technical issues were the most frequent, affecting 84.1% of patients, while biological mishaps impacted 7 out of 44 patients (15.9%). Coil failure occurred in 16 out of 44 patients (36.4%), and stent failure was observed in 14 out of 44 patients (31.8%). Catheter-related problems were noted in 5 patients (11.4%), as were thromboembolic events, also in 5 patients (11.4%). Contrast extravasation was observed in 3 patients (6.8%), and hematoma formation occurred in 1 patient (2.3%). Additionally, 12 out of 44 aneurysms were found to be ruptured (27.3%). In this retrospective study spanning five years, our investigation focused on intraoperative complications in 44 out of 429 patients who underwent endovascular aneurysmal surgery. Our findings underscored that the primary source of these complications was related to technical issues, aligning with observations from previously referenced studies. Notably, coil and stent failures emerged as prominent concerns, along with catheter-related problems and thromboembolic events. CONCLUSION: In conclusion, the endovascular approach to treating aneurysms, while offering a minimally invasive option, is not exempt from inherent risks and complications. Despite these challenges, endovascular neurosurgery continues to hold significant value as a crucial alternative for the treatment of intracerebral aneurysms.

Endovascular Treatment of Small Anterior Communicating Artery Aneurysms: Safety and Efficacy in a Contemporary Cohort.

Endovascular treatment (EVT) of small anterior communicating artery (ACoA) aneurysms accompanies a high risk of intraprocedural rupture (IR) because of anatomic location and aneurysm orientation. In this study, we aimed to investigate the safety and efficacy of EVT for small ACoA aneurysms in a contemporary cohort. ACoA aneurysms treated at the Medical University of South Carolina between April 2012 and March 2022 were retrospectively analyzed. Periprocedural baseline characteristics, aneurysm size, and clinical and radiological outcomes were collected. Aneurysms were dichotomized into <4 and ≥4 mm in maximum size. The IR rate, favorable occlusion rate (Raymond-Roy I and II), and the favorable outcome defined as modified Rankin Scale 0-2 were compared. A total of 174 patients were identified, of whom 111 (63.8%) were female, and the median age was 57.7 (interquartile range 50.6-69.6) years. 98 (56.3%) aneurysms were ruptured, and 53 (30.5%) were <4 mm. IR was not observed in unruptured ACoA aneurysms, and there was no significant difference in the IR rates between <4 mm and ≥4 mm ruptured aneurysms (6.5% vs 4.5%, P = .65). Favorable occlusion rate and favorable outcome were observed in 94.7% and 78.2% of patients, respectively. EVT of small ACoA aneurysms is safe and effective.

Predictive value of the anterior communicating artery (ACoA) complex variations for the incidence and rupture of ACoA aneurysms

BackgroundIncrease pressure on arteries branching points and curves (hyperdynamic theory) is the most popular theory to explain the aneurysms formation that augmented by the observation of high incidence of anomalies (either A1 aplasia or hypoplasia) and the anterior communicating artery (ACoA) aneurysms. It still underestimated the correlation between these anatomical anomalies and aneurysm occurrence and its rupture. We aim to estimate the incidence and type of anatomical anomalies of the anterior cerebral circulation, including the A2 segment in patients with ACoA aneurysms and their predictive value for aneurysm occurrence and rupture parallel to the risk of hypertension. Also, we study the impact of these anomalies on the configuration of the aneurysm, including the neck and size.ResultsA1 hypoplasia and aplasia were significantly higher in AcoA aneurysms group than in the control group (P < 0.001 and 0.002, respectively). These anomalies have no significant statistical difference between rupture and unruptured ACoA aneurysms. A2 anomalies were insignificantly different between both groups.ConclusionCongenital anomalies in the A1 segment (hypoplasia and aplasia) have a significant predictive value for AcoA aneurysms formation, with no predictive value for the aneurysm rupture. Concomitantly, A2 anomalies have no significant risk for AcoA aneurysms formation and rupture.

Rathke’s cleft cyst discovered with ruptured anterior communicating artery aneurysm: a case report

IntroductionRathke’s cleft cysts are thought to have a benign clinical outcome apart from associated hypopituitarism and visual defects. Synchronous central nervous system lesions, including pituitary adenoma and intracerebral aneurysms, are rarely reported. Diagnosis of Rathke’s cleft cyst after presenting with a subarachnoid hemorrhage due to a ruptured arterial aneurysm is reported only once before.Case presentationA 33-year-old Sri Lankan female presented with a subarachnoid hemorrhage due to a ruptured anterior communication artery aneurysm. She underwent pterional craniotomy and aneurysm clipping. She was found to have partial cranial diabetes insipidus and hypogonadotropic hypogonadism. She had a cystic lesion occupying enlarged sella turcica with characteristics of a Rathke’s cleft cyst. Subsequently, she underwent trans-sphenoidal excision of the sellar lesion. Histology confirmed the diagnosis of Rathke’s cleft cyst.ConclusionsRare co-occurrence of a Rathke’s cleft cyst and an anterior communicating artery aneurysm would have been missed if subtle manifestations atypical for subarachnoid hemorrhage were not further pursued. This could have led to progressive visual deterioration and hypopituitarism.

Impact on collateral flow of devices used for endovascular treatment of stroke: an in-vitro flow model

BackgroundCollateral blood supply of distal vessels has been linked to clinical outcome, infarct volume and recanalization rates in patients with large vessel occlusion. Our study aimed to explore the effects...

Flow diversion for the treatment of intracranial bifurcation aneurysms: a systematic review and meta-analysis

BackgroundFlow diversion (FD: flow diversion, flow diverter) is an endovascular treatment for many intracranial aneurysm types; however, limited reports have explored the use of FDs in bifurcation aneurysm management. We...

Importance of Preoperative Vertical Geometric Analysis in Surgery for Anterior Communicating Artery Aneurysm.

In this study, we analyzed the vertical geometry of the anterior communicating artery (AComA) complex with the aim to improve the surgical site orientation during aneurysm operations. Further, the geometric data that can contribute to the success of the surgical technique applied for AComA aneurysms are reported. Computed tomography angiography data of the cerebral arteries of 100 patients who visited our clinic were analyzed. A three-dimensional examination was performed according to the Frankfurt horizontal plane (FHP) using the RadiAnt DICOM Viewer (Medixant, Poznan, Poland), and vertical measurements of the AComA complex were calculated. The Willis polygon values were found to be consistent with those in the literature. The mean height of the AComA complex was 30.58 ± 4.80 mm according to the FHP. Preoperative evaluation of the vertical geometry of the AComA complex is essential for AComA aneurysm surgery. The height of the AComA complex is a key parameter affecting intraoperative surgical site visibility. Preoperative calculation of the height of the AComA complex relative to FHP can facilitate intraoperative surgical site orientation.

Delayed intraoperative rupture of clipped aneurysm during the awaking from anaesthesia

Introduction. Intraoperative rupture (IOR) of an aneurysm is a frightful complication that causes significant morbidity and mortality worldwide. IOR can be attributed to various parameters, including hypertension, increased intracranial pressure (ICP), fragility of the vessels, and inadequate anaesthesia. IOR due to insufficient anaesthesia is scarcely reported in the literature. Here, we describe a re-ruptured anterior communicating artery (ACoA) after incomplete clipping of the neck during craniotomy closure due to unintended early wake-up from anaesthesia with a discussion about the management. Case description. A 38-year-old male suddenly developed a severe headache, a brief loss of consciousness, and vomiting. Computed tomography (CT) scan showed a subarachnoid haemorrhage in the basal cistern. CT angiography showed a bilobed right ACoA aneurysm with a wide neck and Murphy's teat. The patient was considered for surgery. Clipping of the aneurysm neck was done through two curved clips. During craniotomy closure, the patient started coughing and gagging then a huge IOR was encountered. These events can be mainly attributed to unintended inadequate anaesthesia, particularly muscle relaxants. The bleeding ceased after two suction catheters were inserted, temporary clips were applied, and the readjustment of permanent clips. After surgery, the patient showed a left-sided weakness. His postoperative CT scan showed a right distal anterior cerebral artery (ACA) territory infarction. The weakness improved in the follow-up period. Conclusion. Delayed IOR due to early awaking from anaesthesia should be considered a potential source of complications and bad outcomes in aneurysm surgery.

Clinical and Morphological Factors for Ruptured Anterior Communicating Artery Aneurysms.

The anterior communicating artery (ACoA) aneurysm, the most frequent cerebral aneurysm to rupture, carries a significant clinical burden, yet the factors influencing its rupture are limited in Indonesia. This study aims to determine the clinical and morphological features associated with ruptured ACoA compared to non-AcoA aneurysms among Indonesians. We retrospectively reviewed our center's aneurysm patient registry from January 2019 to December 2022, and compared the clinical and morphological features between ruptured ACoA aneurysms and ruptured aneurysms elsewhere with univariate and multivariate analyses. Of the 292 patients with 325 ruptured aneurysms, 89 were from ACoA. The mean age of patients was 54.99 years, with female preponderance in the non-ACoA group (non-ACoA: 73.31%, ACoA: 46.07%). On univariate analysis, ages ≥60 [ages 60-69: OR = 0.311 (0.111-0.869), p=0.026; ages ≥70: OR = 0.215 (0.056-0.819), p=0.024], female gender [OR = 0.311 (0.182-0.533), p<0.001], and smoking [OR=2.069 (1.036-4.057), p=0.022] exhibited significant association with ruptured ACoA aneurysm. On multivariate analysis, only the female gender was independently associated with ruptured ACoA aneurysm (aOR 0.355 [0.436-1.961], p=0.001). In our study, ruptured ACoA aneurysm was inversely associated with advanced age, female gender, presence of daughter aneurysm, and directly associated with smoking. After multivariate adjustment, the female gender showed an independent association with ruptured ACoA aneurysm.

Effect of anterior communicating artery patency on the flow velocity in bilateral carotid artery stenosis after carotid endarterectomy.

The effect of anterior communicating artery (ACoA) patency on the flow velocity of the extracranial carotid arteries is unclear. A total of 285 patients with carotid artery stenosis were included between January 2019 and January 2021. All patients received unilateral carotid endarterectomy (CEA). The patients were classified into ACoA-patent (161) and ACoA-nonpatent (124) groups using digital subtraction angiography (DSA) and/or computed tomography angiography (CTA). The peak systolic velocity (PSV) and end-diastolic velocity (EDV) measured by carotid duplex ultrasonography (CDU) were compared between both groups, pre- and post-CEA. There was no significant difference in the risk factors for cerebrovascular disease between the two groups. Within 1 week after CEA, the PSV and EDV on operative and nonoperative carotid (contralateral carotid in the same patient) arteries decreased significantly (both p < 0.01). Comparison of nonoperative carotid artery pre- and post-CEA between the two groups showed that post-CEA PSV and EDV in the ACoA-patent group were significantly lower than that of pre-CEA (PSV and EDV, t = 11.507 and 6.716, respectively, both p < 0.001) (according to the Society of Radiologists in Ultrasound Consensus Conference [SRUCC] PSV standard). There was no significant difference in the ACoA-nonpatent group (PSV: t = 1.924, p = 0.057; EDV: t = 1.237, p = 0.218). In the nonoperative carotid artery of the ACoA-patent group, the degree of stenosis assessed by CDU was inconsistent with that of DSA/CTA (κ = 0.294), whereas that in the ACoA-nonpatent group had a high consistency (κ = 0.982). Among 161 ACoA-patent cases, 68 showed overestimated stenosis. The patent ACoA increases PSV and EDV, causing an overestimation of carotid artery stenosis.

Terson Syndrome: Not to Be Missed in Patients with Disorders of Consciousness

The diagnosis of clinical cognitive motor dissociation (cCMD) can be hindered by pitfalls during standardized clinical evaluation based on gold-standard neurobehavioral rating scales. We introduce here a new pitfall, by reporting two cases of Terson syndrome (TS) after subarachnoid haemorrhage (SAH) caused by the rupture of an anterior communicant artery aneurysm, hospitalized in the Acute Neurorehabilitation Unit (ANR) of CHUV. TS is reported to occur in 8–19.3% of patients suffering from SAH. It can lead to significant visual impairment and if unrecognized, may impair the patient’s capacity to interact appropriately with the environment; it thus presents an important pitfall in recognizing clinical cognitive–motor dissociation (cCMD) in patients with altered states of consciousness. An early ophthalmological exam should be considered in all patients with SAH and disorders of consciousness or visual complaints.

Microsurgical clipping as a retreatment strategy for previously ruptured aneurysms treated with the Woven EndoBridge (WEB) device: a mono-institutional case series

BackgroundSince its approval by the US Food and Drug Administration (FDA) in 2018, the flow disruptor Woven EndoBridge (WEB) device has become increasingly popular for the endovascular treatment of unruptured and ruptured cerebral aneurysms. However, the occlusion rates seem rather low and the retreatment rates rather high compared to other treatment methods. For initially ruptured aneurysms, a retreatment rate of 13 % has been reported. A variety of retreatment strategies has been proposed; however, there is a paucity of data concerning microsurgical clipping of WEB-pretreated aneurysms, especially previously ruptured ones. Thus, we present a single-center series of five ruptured aneurysms treated with the WEB device and retreated with microsurgical clipping.MethodsA retrospective study including all patients presenting with a ruptured aneurysm undergoing WEB treatment at our institution between 2019 and 2021 was performed. Subsequently, all patients with an aneurysm remnant or recurrence of the target aneurysm retreated with microsurgical clipping were identified.ResultsOverall, five patients with a ruptured aneurysm treated with WEB and retreated with microsurgical clipping were included. Besides one basilar apex aneurysm, all aneurysms were located at the anterior communicating artery (AComA) complex. All aneurysms were wide-necked with a mean dome-to-neck ratio of 1.5. Clipping was feasible and safe in all aneurysms, and complete occlusion was achieved in 4 of 5 aneurysms.ConclusionsMicrosurgical clipping for initially ruptured WEB-treated aneurysms is a feasible, safe, and effective treatment method in well-selected patients.

Funnel Shaped Anterior Communicating Artery Fenestration Mistaken for an Aneurysm: A Cautionary Tale

This report portrays a case of a funnel shaped anterior communicating artery (ACoA) fenestration which was mistaken as a small A1 aneurysm in a subarachnoid hemorrhage case. Although tridimensional rotational digital subtraction angiography improves aneurysm diagnosis specially at the ACoA complex, current spatial resolution might leave behind a considerable percentage of ACoA fenestrations. This may lead to diagnostic errors and unnecessary treatments risking iatrogenic complications. Luckily for our patient, a concomitant aneurysm warranted clipping and subsequent surgical exploration of the ACoA complex revealed the pitfall, thus preventing further action. Interestingly, another group of authors who reported similar misdiagnosis with ACoA aneurysms were able to prevent a third error, thanks to the experience acquired with 2 prior cases. Therefore, this clinical image aims to raise wider awareness of the need for very cautious consideration of imaging depicting small and/or atypical aneurysms in the ACoA complex.

Letter to the Editor Regarding “Clinical Utility of Routine Postprocedural Computed Tomography of the Head Following Elective Neuroendovascular Interventions”

This report portrays a case of a funnel shaped anterior communicating artery (ACoA) fenestration which was mistaken as a small A1 aneurysm in a subarachnoid hemorrhage case. Although tridimensional rotational digital subtraction angiography improves aneurysm diagnosis specially at the ACoA complex, current spatial resolution might leave behind a considerable percentage of ACoA fenestrations. This may lead to diagnostic errors and unnecessary treatments risking iatrogenic complications. Luckily for our patient, a concomitant aneurysm warranted clipping and subsequent surgical exploration of the ACoA complex revealed the pitfall, thus preventing further action. Interestingly, another group of authors who reported similar misdiagnosis with ACoA aneurysms were able to prevent a third error, thanks to the experience acquired with 2 prior cases. Therefore, this clinical image aims to raise wider awareness of the need for very cautious consideration of imaging depicting small and/or atypical aneurysms in the ACoA complex.