Microsurgical Treatment of Anterior Communicating Artery Aneurysms: An Analysis of 74 Consecutive Cases. Approach Side Choice and Outcome Considerations

Abstract

Introduction Anterior communicating artery aneurysms (ACoAAs) are intracranial aneurysms whose treatment is still considered a challenging task.

Materials and Methods Altogether, 74 patients were included in this study. The variables included age, sex, comorbidities, incidence of subarachnoid hemorrhage (SAH), the Fisher, Hunt-Hess, and WFNS scores, approach side, length of hospital stay, and mortality. We also investigate A1/A2 dimensions, association with approach side choice and the influence of surgeon's experience on the outcome.

Results There were 61 patients (82.2%) admitted with SAH and 13 were treated for unruptured aneurysms. The A1 and A2 branches were larger ipsilaterally to the selected approach side (p < 0,001). No deaths occurred in the unruptured aneurysm group. In the SAH group, mortality was strongly correlated with the Hunt-Hess score (p < 0.001), Fisher grade (p < 0.001), and WFNS score (p < 0.001). No significant difference was found in mortality between the right-side and the left-side approaches (p = 0.253). A significant survival difference was identified on the group operated by the senior surgeon versus the non-senior group (p = 0.048).

Discussion and Conclusion A1 dominance was identified as a factor associated to the approach side for SAH cases at our center. Understanding the factors involved in brain aneurysm surgery remains a relevant and underexplored subject. Further studies involving larger case series and multicenter collaborations are necessary to elucidate these factors and to determine the external validity of our findings.

Resumo

Introdução Os aneurismas da artéria comunicante anterior (ACoAA) são aneurismas intracranianos cujo tratamento ainda é considerado uma tarefa desafiadora.

Materiais e Métodos Ao todo, 74 pacientes foram incluídos neste estudo. As variáveis incluíram idade, sexo, comorbidades, incidência de hemorragia subaracnóidea (HAS), escala de Fisher, Hunt-Hess e WFNS, lado de abordagem, tempo de internação e mortalidade. Também investigamos as dimensões A1/A2, a associação com a escolha do lado de abordagem e a influência da experiência do cirurgião no resultado.

Resultados Foram admitidos 61 pacientes (82,2%) com HAS e 13 foram tratados por aneurismas não rotos. Os ramos A1 e A2 foram maiores ipsilateralmente ao lado de abordagem selecionada (p < 0,001). Nenhuma morte ocorreu no grupo de aneurismas não rotos. No grupo HAS, a mortalidade esteve fortemente correlacionada com a escala de Hunt-Hess (p < 0,001), pontuação de Fisher (p < 0,001) e pontuação WFNS (p < 0,001). Não foi encontrada diferença significativa na mortalidade entre as abordagens direita e esquerda (p = 0,253). Foi identificada diferença significativa de sobrevida no grupo operado pelo cirurgião sênior versus o grupo não sênior (p = 0,048).

Discussão e Conclusão A dominância A1 foi identificada como fator associado ao lado de abordagem dos casos de HAS em nosso centro. A compreensão dos fatores envolvidos na cirurgia de aneurisma cerebral permanece um assunto relevante e pouco explorado. Mais estudos envolvendo séries de casos maiores e colaborações multicêntricas são necessários para elucidar esses fatores e para determinar a validade externa de nossas descobertas.

Keywords

vascular neurosurgery - anterior communicating artery aneurysm - subarachnoid hemorrhage - microsurgery

Palavras-chave

neurocirurgia vascular - aneurisma da artéria comunicante anterior - hemorragia subaracnoídea - microcirurgia

Publikationsverlauf

Eingereicht: 22. August 2022

Angenommen: 24. Januar 2023

Artikel online veröffentlicht:
27. Oktober 2023

• References

• 1 Hernesniemi J, Dashti R, Lehecka M. et al. Microneurosurgical management of anterior communicating artery aneurysms. Surg Neurol 2008; 70 (01) 8-28 , discussion 29 DOI: 10.1016/j.surneu.2008.01.056.
• 2 Rhoton Jr AL, Perlmutter D. Microsurgical anatomy of anterior communicating artery aneurysms. Neurol Res 1980; 2 (3-4): 217-251 DOI: 10.1080/01616412.1980.11739581.
• 3 Lindvall P, Runnerstam M, Birgander R, Koskinen LO. The Fisher grading correlated to outcome in patients with subarachnoid haemorrhage. Br J Neurosurg 2009; 23 (02) 188-192 DOI: 10.1080/02688690802710668.
• 4 Hyun SJ, Hong SC, Kim JS. Side selection of the pterional approach for superiorly projecting anterior communicating artery aneurysms. J Clin Neurosci 2010; 17 (05) 592-596
• 5 Agrawal A, Jagetia A, Bodeliwala S, Singh D, Dutta G, Shah A. Intraoperative microsurgical anatomy of the anterior communicating artery complex harbouring an anterior cerebral territory aneurysm. Neurol India 2019; 67 (03) 823-828 DOI: 10.4103/0028-3886.263174.
• 6 Bohnstedt BN, Conger AR, Edwards J. et al. Anterior Communicating Artery Complex Aneurysms: Anatomic Characteristics as Predictors of Surgical Outcome in 300 Cases. World Neurosurg 2019; 122: e896-e906 DOI: 10.1016/j.wneu.2018.10.172.
• 7 van Lindert EJ, Böcher-Schwarz HG, Perneczky A. The influence of surgical experience on the rate of intraoperative aneurysm rupture and its impact on aneurysm treatment outcome. Surg Neurol 2001; 56 (03) 151-156 , discussion 156–158 DOI: 10.1016/s0090-3019(01)00547-x.
• 8 Le Reste PJ, Henaux PL, Riffaud L, Haegelen C, Morandi X. Influence of cumulative surgical experience on the outcome of poor-grade patients with ruptured intracranial aneurysm. Acta Neurochir (Wien) 2015; 157 (01) 1-7 DOI: 10.1007/s00701-014-2241-3.
• 9 Ahmed O, Zhang S, Brown BL. et al. Anterior communicating artery aneurysm: Accuracy of CT angiography in determination of inflow dominance. Neuroradiol J 2015; 28 (04) 389-395 DOI: 10.1177/1971400915594503.
• 10 Soares FP, Velho MC, Antunes ACM. Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil. Surg Neurol Int 2019; 10: 193 DOI: 10.25259/sni_41_2019.
• 11 Heit JJ, Ball RL, Telischak NA. et al. Patient Outcomes and Cerebral Infarction after Ruptured Anterior Communicating Artery Aneurysm Treatment. AJNR Am J Neuroradiol 2017; 38 (11) 2119-2125 DOI: 10.3174/ajnr.A5355.
• 12 Proust F, Hannequin D, Langlois O, Freger P, Creissard P. Causes of morbidity and mortality after ruptured aneurysm surgery in a series of 230 patients. The importance of control angiography. Stroke 1995; 26 (09) 1553-1557 DOI: 10.1161/01.str.26.9.1553.
• 13 Post KD, Flamm ES, Goodgold A, Ransohoff J. Ruptured intracranial aneurysms. Case morbidity and mortality. J Neurosurg 1977; 46 (03) 290-295 DOI: 10.3171/jns.1977.46.3.0290.
• 14 Alotaibi NM, Ibrahim GM, Wang J. et al. Neurosurgeon academic impact is associated with clinical outcomes after clipping of ruptured intracranial aneurysms. PLoS One 2017; 12 (07) e0181521 DOI: 10.1371/journal.pone.0181521.
• 15 Maurice-Williams RS, Kitchen ND. Ruptured intracranial aneurysms–learning from experience. Br J Neurosurg 1994; 8 (05) 519-527 DOI: 10.3109/02688699409002944.
• 16 Lawton MT, Du R. Effect of the neurosurgeon's surgical experience on outcomes from intraoperative aneurysmal rupture. Neurosurgery 2005; 57 (01) 9-15 , discussion 9–15 DOI: 10.1227/01.neu.0000163082.20941.ef.
• 17 Andaluz N, Zuccarello M. Anterior Communicating Artery Aneurysm Surgery through the Orbitopterional Approach: Long-Term Follow-Up in a Series of 75 Consecutive Patients. Skull Base 2008; 18 (04) 265-274 DOI: 10.1055/s-2008-1058367.
• 18 Figueiredo EG, Deshmukh P, Zabramski JM. et al. Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex. Neurosurgery 2005; 56 (02) 397-405 , discussion 397–405 DOI: 10.1227/01.neu.0000156549.96185.6d.
• 19 Diraz A, Kobayashi S, Toriyama T, Ohsawa M, Hokama M, Kitazama K. Surgical approaches to the anterior communicating artery aneurysm and their results. Neurol Res 1993; 15 (04) 273-280 DOI: 10.1080/01616412.1993.11740148.
• 20 Suzuki M, Fujisawa H, Ishihara H, Yoneda H, Kato S, Ogawa A. Side selection of pterional approach for anterior communicating artery aneurysms–surgical anatomy and strategy. Acta Neurochir (Wien) 2008; 150 (01) 31-39 , discussion 39 DOI: 10.1007/s00701-007-1466-9.
• 21 Ikawa F, Morita A, Tominari S. et al; Japan Neurosurgical Society for UCAS Japan Investigators. Rupture risk of small unruptured cerebral aneurysms. J Neurosurg 2019; •••: 1-10 DOI: 10.3171/2018.9.Jns181736.
• 22 Ujiie H, Liepsch DW, Goetz M, Yamaguchi R, Yonetani H, Takakura K. Hemodynamic study of the anterior communicating artery. Stroke 1996; 27 (11) 2086-2093 , discussion 2094 DOI: 10.1161/01.str.27.11.2086.
• 23 Roach MR, Scott S, Ferguson GG. The hemodynamic importance of the geometry of bifurcations in the circle of Willis (glass model studies). Stroke 1972; 3 (03) 255-267 DOI: 10.1161/01.str.3.3.255.
• 24 Flores BC, Scott WW, Eddleman CS, Batjer HH, Rickert KL. The A1-A2 diameter ratio may influence formation and rupture potential of anterior communicating artery aneurysms. Neurosurgery 2013; 73 (05) 845-853 , discussion 852–853 DOI: 10.1227/neu.0000000000000125.