Ruptured anterior communicating artery aneurysm outcome of microvascular clipping compared to endovascular coiling

see also Ruptured Intracranial aneurysm outcome of microvascular clipping compared to endovascular coiling

Patients with very small ruptured anterior communicating artery aneurysm can be safely and effectively treated with endovascular coiling. However, smaller ACoA aneurysms still require surgical clipping. A smaller aneurysm size limits the use of endovascular coiling 1).

The prevention and impact of recurrence and residual aneurysms remains incompletely understood. Hence, treatment decisions should be taken by patients after they have been given carefully considered recommendations from the multi-disciplinary team 2)

Attention should be paid not only to the anatomical characteristics of the aneurysm itself but also to the adjacent important blood vessels and perforating arteries; therefore, both surgical clipping and endovascular embolization are serious challenges for neurosurgeons. No matter which treatment is chosen, it is necessary to determine the structure of the Anterior communicating artery and its perforating arteries as well as whether there is a fenestration deformity of the Anterior communicating artery and the relationship between bilateral A1-A2 before surgery. The shape and size of the aneurysm itself and its location relative to adjacent blood vessels also need to be considered to better complete the procedure, and this is especially true for microsurgical clipping. Clarifying the anatomy before surgery is helpful for better selecting the surgical approach and surgical side, which could affect the intraoperative exposure of the aneurysm and adjacent arteries, the surgical difficulty, the resection rate, and the postoperative complications. Therefore, starting with Anterior communicating artery aneurysms and their adjacent structures and variations 3)

Frontal lobe and recurrent artery of Heubner infarctions are more common after surgical clipping of ruptured anterior communicating artery aneurysms, and are associated with poorer clinical outcomes at discharge 4)

There was no difference in age between the treatment modalities. Risks of complications are present and specific for both modalities 5).

The clinical outcomes of microsurgical clipping versus endovascular coiling have been reported in systematic reviews for other intracranial aneurysm locations, including middle cerebral artery aneurysm and posterior communicating artery aneurysms. A systematic review is necessary to evaluate the functional, angiographic, and safety outcomes of endovascular management versus microsurgical clipping for treatment guidelines.

Inclusion criteria: Patients aged 18 years and over with a ruptured anterior communicating artery aneurysm will be included. Patients may have intracranial aneurysms in other locations; however, they will only be included if a ruptured anterior communicating artery aneurysm has occurred and only if that aneurysm has been treated. Interventions of interest are microsurgical clipping compared to endovascular treatment.

Methods: The following databases will be searched: PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials. Experimental, quasi-experimental, and analytical observational studies will be considered. Studies in all languages will be included if they can be translated. Two independent reviewers will retrieve and assess relevant studies using JBI’s critical appraisal tools. Extracted data will include Glasgow Outcome Scale/Modified Rankin Score, angiographic occlusion, aneurysm recurrence, intra-operative thromboembolic event rates, post-operative complications, and post-operative aneurysm recurrence rates. Studies will, where possible, be pooled using statistical meta-analysis. Outcomes assessed will include functional status, angiographic occlusion rates, incidence of aneurysm recurrence, and safety of treatment 6).

Because the fields of microvascular and endovascular surgeries are both technically complex, there has been concern that hybrid cerebrovascular surgeons cannot perform each technique with the skill necessary to achieve good outcomes. When compared to clipping and coiling reviews in the neurosurgical literature, we illustrate that one hybrid neurovascular surgeon is capable of attaining great facility in both techniques and that this type of physician will represent one practice model of cerebrovascular specialist in the future. This has potential implications for the training of hybrid cerebrovascular surgeons 7)

Zhao B, Xing H, Fan L, Tan X, Zhong M, Pan Y, Wan J. Endovascular Coiling versus Surgical Clipping of Very Small Ruptured Anterior Communicating Artery Aneurysms. World Neurosurg. 2019 Jun;126:e1246-e1250. doi: 10.1016/j.wneu.2019.03.074. Epub 2019 Mar 18. PMID: 30898747.
Harris L, Hill CS, Elliot M, Fitzpatrick T, Ghosh A, Vindlacheruvu R. Comparison between outcomes of endovascular and surgical treatments of ruptured anterior communicating artery aneurysms. Br J Neurosurg. 2021 Jun;35(3):313-318. doi: 10.1080/02688697.2020.1812517. Epub 2020 Aug 27. PMID: 32852231.
Chen J, Li M, Zhu X, Chen Y, Zhang C, Shi W, Chen Q, Wang Y. Anterior Communicating Artery Aneurysms: Anatomical Considerations and Microsurgical Strategies. Front Neurol. 2020 Sep 8;11:1020. doi: 10.3389/fneur.2020.01020. Erratum in: Front Neurol. 2020 Nov 20;11:620226. PMID: 33013671; PMCID: PMC7509403.
Heit JJ, Ball RL, Telischak NA, Do HM, Dodd RL, Steinberg GK, Chang SD, Wintermark M, Marks MP. Patient Outcomes and Cerebral Infarction after Ruptured Anterior Communicating Artery Aneurysm Treatment. AJNR Am J Neuroradiol. 2017 Nov;38(11):2119-2125. doi: 10.3174/ajnr.A5355. Epub 2017 Sep 7. PMID: 28882863; PMCID: PMC7963583.
Navrátil O, Ďuriš K, Juráň V, Svoboda K, Hustý J, Hovorka E, Neuman E, Mrlian A, Smrčka M. Current Treatment of Anterior Communicating Artery Aneurysms: Single Center Study. Brain Sci. 2020 Jul 31;10(8):501. doi: 10.3390/brainsci10080501. PMID: 32751951; PMCID: PMC7465251.
Nowicki J, Harding M, Aromataris E. Clinical outcomes of microvascular clipping compared to endovascular coiling for ruptured anterior communicating artery aneurysms: a systematic review protocol. JBI Evid Synth. 2022 Aug 1;20(8):2032-2039. doi: 10.11124/JBIES-21-00332. PMID: 35971201.
Alexander BL, Riina HA. The combined approach to intracranial aneurysm treatment. Surg Neurol. 2009 Dec;72(6):596-606; discussion 606. doi: 10.1016/j.surneu.2009.06.027. Epub 2009 Oct 9. PMID: 19818994.
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