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anterior_communicating_artery_aneurysm_treatment

Anterior communicating artery aneurysm treatment

The aspect ratio, direction of the dome, and fenestration should be examined most meticulously when deciding when to treat an Anterior communicating artery aneurysm 1).

The direction in which the fundus projects was chosen as the morphological criterion between endovascular and surgical methods. Proust et al. proposed that microsurgical clip application should be the preferred option in the treatment of ACoA aneurysms with anteriorly directed fundi and that endovascular packing be selected for those lesions with posteriorly directed fundi, depending on morphological criteria 2).

Endovascular coiling (EC) resulted in a more favorable clinical outcome, and microsurgical clipping (MC) resulted in more robust aneurysm repair, for unruptured ACoA aneurysms. Stent assisted coiling (SAC) had a higher treatment morbidity risk than EC, without reduction in retreatment rate. All treatments were effective in preventing SAH. The current pooled analysis of treatment outcomes provides a useful aid to pretreatment clinical decision making 3).


Morphological Scoring System of Choi 4).

Endovascular treatment

Surgery

Case series

The prospective study included 223 patients who were divided into three groups: Group A (83 microsurgically treated patients, 1990-1995); Group B (103 microsurgically treated patients, 1996-2000); and Group C (37 patients treated with Guglielmi Detachable Coil [GDC] embolization, 1996-2000). Depending on the direction in which the aneurysm fundus projected, the authors attempted to apply microsurgical treatment to Type 1 aneurysms (located in front of the axis formed by the pericallosal arteries). They proposed the most adapted procedure for Type 2 aneurysms (located behind the axis of the pericallosal arteries) after discussion with the neurovascular team, depending on the physiological status of the patient, the treatment risk, and the size of the aneurysm neck. In accordance with the classification of Hunt and Hess, the authors designated those patients with unruptured aneurysms (Grade 0) and some patients with ruptured aneurysms (Grades I-III) as having good preoperative grades. Patients with Grade IV or V hemorrhages were designated as having poor preoperative grades. By performing routine angiography and computerized tomography scanning, the causes of unfavorable outcome (Glasgow Outcome Scale [GOS] score < 5) and the morphological results (complete or incomplete occlusion) were analyzed. Overall, the clinical outcome was excellent (GOS Score 5) in 65% of patients, good (GOS Score 4) in 9.4%, fair (GOS Score 3) in 11.6%, poor (GOS Score 2) in 3.6%, and fatal in 10.3% (GOS Score 1). Among 166 patients in good preoperative grades, an excellent outcome was observed in 134 patients (80.7%). The combined permanent morbidity and mortality rate accounted for up to 19.3% of patients. The rates of permanent morbidity and death that were related to the initial subarachnoid hemorrhage were 6.2 and 1.5% for Group A, 6.6 and 1.3% for Group B, and 4 and 4% for Group C, respectively. The rates of permanent morbidity and death that were related to the procedure were 15.4 and 1.5% for Group A, 3.9 and 0% for Group B, and 8 and 8% for Group C, respectively. When microsurgical periods were compared, the rate of permanent morbidity or death related to microsurgical complications decreased significantly (Group A, 11 patients [16.9%] and Group B, three patients [3.9%]); Fisher exact test, p = 0.011) from the period of 1990 to 1995 to the period of 1996 to 2000. The combined rate of morbidity and mortality that was related to the endovascular procedure (16%) explained the nonsignificance of the different rates of procedural complications for the two periods, despite the significant decrease in the number of microsurgical complications. Among 57 patients in poor preoperative grade, an excellent outcome was observed in 11 patients (19.3%); however, permanent morbidity (GOS Scores 2-4) or death (GOS Score 1) occurred in 46 patients (80.7%). With regard to the correlation between vessel occlusion (the primary microsurgical complication) and the morphological characteristics of aneurysms, only the direction in which the fundus projected appeared significant as a risk factor for the microsurgically treated groups (Fisher exact test: Group A, p = 0.03; Group B, p = 0.002). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (chi2 = 6.13, p = 0.01).

The direction in which the fundus projects was chosen as the morphological criterion between endovascular and surgical methods. The authors propose that microsurgical clip application should be the preferred option in the treatment of ACoA aneurysms with anteriorly directed fundi and that endovascular packing be selected for those lesions with posteriorly directed fundi, depending on morphological criteria 5).

1)
Cai W, Hu C, Gong J, Lan Q. Anterior Communicating Artery Aneurysm Morphology and the Risk of Rupture. World Neurosurg. 2018 Jan;109:119-126. doi: 10.1016/j.wneu.2017.09.118. Epub 2017 Sep 27. Review. PubMed PMID: 28958928.
2) , 5)
Proust F, Debono B, Hannequin D, Gerardin E, Clavier E, Langlois O, Fréger P. Treatment of anterior communicating artery aneurysms: complementary aspects of microsurgical and endovascular procedures. J Neurosurg. 2003 Jul;99(1):3-14. PubMed PMID: 12854737.
3)
O'Neill AH, Chandra RV, Lai LT. Safety and effectiveness of microsurgical clipping, endovascular coiling, and stent assisted coiling for unruptured anterior communicating artery aneurysms: a systematic analysis of observational studies. J Neurointerv Surg. 2016 Sep 13. pii: neurintsurg-2016-012629. doi: 10.1136/neurintsurg-2016-012629. [Epub ahead of print] Review. PubMed PMID: 27624158.
4)
Choi JH, Kang MJ, Huh JT. Influence of clinical and anatomic features on treatment decisions for anterior communicating artery aneurysms. J Korean Neurosurg Soc. 2011 Aug;50(2):81-8. doi: 10.3340/jkns.2011.50.2.81. Epub 2011 Aug 31. PubMed PMID: 22053224; PubMed Central PMCID: PMC3206283.
anterior_communicating_artery_aneurysm_treatment.txt · Last modified: 2019/08/14 07:59 by administrador