Surgical Treatment of Anterior Communicating Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

Abstract

Background Anterior communicating artery (AComA) aneurysms are the most common intracranial aneurysm, accounting for 25 to 38% of all cases. In spite of the advent of modern neurointerventional treatments, they still represent a strong indication for clipping in certain anatomical and clinical conditions. However, AComA aneurysms are the deepest located aneurysms of the anastomotic circle of Willis, with a complex spatial orientation, and they are fed by bilateral branches of the anterior circulations. Although, on one hand, these aneurysms represent the most complex ones of the anterior circulation, on the other hand, the experience of young neurosurgeons is increasingly limited. Therefore, respecting operative guidelines is crucial to achieve the best aneurysm exclusion and avoid fatal intraoperative complications.

Study Objective We describe the technical algorithm we use to teach young neurosurgeons how to approach AComA aneurysms and help them to develop a procedural memory needed to perform an efficient and safe surgery.

Materials and Methods We reviewed our last 10 years of institutional experience of > 200 cases of clipping ruptured and unruptured AComA aneurysms, analyzing our technical refinements and the difficulties in teaching residents and young neurosurgeons how to establish fundamental key points and design a didactic algorithm that includes operative instructions and safety rules.

Results We identified seven pragmatic technical key points regarding craniotomy, cisternostomy, gyrus rectus corticectomy, proximal control, perforators and Heubner preservation, aneurysm neck dissection, and clipping to use in a didactic algorithm for teaching residents and as operative instructions for inexperienced neurosurgeons.

Conclusion In the setting of clipping AComA aneurysms, respect for surgical rules is of paramount importance to perform an efficacious and safe procedure and ensure the best aneurysm exclusion and preservation of neurovascular structures.

Keywords

anterior communicating artery aneurysm - AComA aneurysms - lateral supraorbital approach - gyrus rectus corticectomy - vascular neurosurgery

Publication History

Received: 24 March 2019

Accepted: 03 July 2019

Article published online:
05 June 2020

• References

• 1 Choque-Velasquez J, Hernesniemi J. Microsurgical clipping of a large ruptured anterior communicating artery aneurysm. Surg Neurol Int 2018; 9: 233
• 2 Quiñones-Hinojosa A. Schmidek & Sweet: Operative Neurosurgical Techniques: Indications, Methods and Results. Vol 2. Philadelphia, PA: Elsevier; 2012: 882-896
• 3 Sturiale CL, Brinjikji W, Murad MH, Cloft HJ, Kallmes DF, Lanzino G. Endovascular treatment of distal anterior cerebral artery aneurysms: single-center experience and a systematic review. AJNR Am J Neuroradiol 2013; 34 (12) 2317-2320
• 4 Sturiale CL, De Waure C, Della Pepa GM. , et al. Endovascular treatment of the posterior cerebral artery aneurysms: single center experience and a systematic review. World Neurosurg 2016; 91: 154-162
• 5 Sturiale CL, Stifano V, Della Pepa GM. , et al. Intracranial aneurysms of the posterior circulation associated with a fenestration: a systematic review. J Neurosurg Sci 2018 (PMID: ; February 23 (Epub ahead of print))
• 6 Lawton MT. Seven Aneurysms: Tenets and Technique for Clipping. New York, NY: Thieme; 2011: 94-135
• 7 Yasargil GM. Microneurosurgery. Vol 2. Stuttgart, Germany: Thieme; 1984: 165-221
• 8 La Rocca G, Della Pepa GM, Sturiale CL. , et al. Lateral supraorbital versus pterional approach: analysis of surgical, functional, and patient-oriented outcomes. World Neurosurg 2018; 119: e192-e199
• 9 Sturiale CL, Marchese E, Puca A, Olivi A, Albanese A. Surgical treatment of posterior communicating artery aneurysms: hints and precautions for young cerebrovascular surgeons. J Neurol Surg A Cent Eur Neurosurg 2019; 80 (03) 205-212
• 10 Koo SK, Song YJ, Huh JT. Surgically treated anterior communicating artery aneurysm. J Korean Neurosurg Soc 2005; 37: 405-409
• 11 Andrews RJ, Spiegel PK. Intracranial aneurysms: characteristics of aneurysms by site, with special reference to anterior communicating artery aneurysms. Surg Neurol 1981; 16 (02) 122-126
• 12 Sturiale CL, La Rocca G, Puca A. , et al. Minipterional craniotomy for treatment of unruptured middle cerebral artery aneurysms. a single-center comparative analysis with standard pterional approach as regard to safety and efficacy of aneurysm clipping and the advantages of reconstruction. Acta Neurochir Suppl (Wien) 2017; 124: 93-100
• 13 Hernesniemi J, Dashti R, Lehecka M. , et al. Microneurosurgical management of anterior communicating artery aneurysms. Surg Neurol 2008; 70 (01) 8-28 ; discussion 29
• 14 Della Pepa GM, Bianchi F, Scerrati A. , et al. Secondary coiling after incomplete surgical clipping of cerebral aneurysms: a rescue strategy or a treatment option for complex cases? Institutional series and systematic review. Neurosurg Rev 2019; 42 (02) 337-350
• 15 Scerrati A, Trovalusci F, Albanese A. , et al. A workflow to generate physical 3D models of cerebral aneurysms applying open source freeware for CAD modeling and 3D printing. Interdiscip Neurosurg 2019; 17: 1-6