Current treatment options and prognostic factors for ruptured distal anterior cerebral artery aneurysms
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
- Department of Neuroendovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
DOI:10.25259/SNI_223_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Yushiro Take1, Tomoya Kamide1, Yuichiro Kikkawa1, Masaki Ikegami1, Akio Teranishi1, Takuro Ehara1, Aoto Shibata1, Kaima Suzuki1, Toshiki Ikeda1, Satoshi Iihoshi2, Shinya Kohyama2, Hiroki Kurita1. Current treatment options and prognostic factors for ruptured distal anterior cerebral artery aneurysms. 19-Apr-2021;12:171
How to cite this URL: Yushiro Take1, Tomoya Kamide1, Yuichiro Kikkawa1, Masaki Ikegami1, Akio Teranishi1, Takuro Ehara1, Aoto Shibata1, Kaima Suzuki1, Toshiki Ikeda1, Satoshi Iihoshi2, Shinya Kohyama2, Hiroki Kurita1. Current treatment options and prognostic factors for ruptured distal anterior cerebral artery aneurysms. 19-Apr-2021;12:171. Available from: https://surgicalneurologyint.com/surgicalint-articles/10736/
Background: Distal anterior cerebral artery (ACA) aneurysms are rare, representing 1–9% of all intracranial aneurysms. The best treatment strategy for these aneurysms continues to be debated. We clarified the clinical features and treatment outcomes of patients with ruptured distal ACA aneurysms according to the treatment options at our institute.
Methods: Thirty-seven consecutive patients (26 women; mean age, 65.2 years) with ruptured distal ACA aneurysms who underwent surgical clipping or coil embolization between 2012 and 2018 were included in the study. Clinical presentations, radiographic findings, and outcomes were retrospectively reviewed and compared between patients who underwent either surgical clipping or coil embolization. Risk factors associated with poor outcomes (modified Rankin Scale 4–6) were analyzed using multiple regression analysis.
Results: Nineteen patients (51.4%) had World Federation Neurological Surgeons (WFNS) Grade IV-V, 18 (48.7%) had frontal lobe hematomas, and 13 (35.1%) had multiple aneurysms. Surgical clipping and endovascular coiling were performed in 28 (75.7%) and nine (24.3%) patients, respectively. Aneurysms located at the A4-5 portions were mainly treated by surgical clipping (P = 0.04). There were no significant between-group differences in procedure-related morbidity and mortality; however, the complete occlusion rate was higher in the surgical group (P
Conclusion: Acceptable outcomes were obtained in 62.5% of cases, and there were no significant between-group differences in treatment results between clipping and coiling. A poor WFNS grade and intracerebral hematomas were risk factors for a poor prognosis.
Keywords: Coil embolization, Poor prognosis, Ruptured distal anterior cerebral aneurysm, Surgical clipping, Treatment outcome
Distal anterior cerebral artery (ACA) aneurysms are rare, representing between 1% and 9% of all intracranial aneurysms.[
A total of 37 consecutive patients (26 women; mean age, 65.2 ± 13.2 years) with ruptured distal ACA aneurysms who underwent surgical clipping or coil embolization at our institute between 2012 and 2018 were included in the analysis. We retrospectively reviewed medical records and radiological studies. All patients were clinically assessed using the World Federation Neurological Surgeons (WFNS) grading scale at the time of admission. The clinical outcome was assessed at the time of discharge using the modified Rankin Scale (mRS), and a poor prognosis was defined as an mRS 4–6. Additionally, we analyzed risk factors of poor prognosis using multiple regression analysis.
We classified the aneurysms into three groups by location: infragenu including the A2 and inferior A3 segments, supragenu including the superior A3 and A4–5 segments, and genu including the area between the infragenu and supragenu. The treatment modalities for ruptured distal ACA aneurysms were selected according to various factors, including clinical status, the patient’s age, and aneurysmal angiographic features. Surgical treatment was preferred for patients with mass-occupying hematomas or those needing decompressive surgery. Surgery was preferred for patients with supragenu aneurysms, whereas endovascular treatment was preferred for patients with infragenu aneurysms. The requirement for written informed consent was waived due to the retrospective nature of the study. This study was approved by the institutional review board of the Saitama Medical University International Medical Center (IRB: 18–124).
Patients’ characteristics — including clinical data, aneurysm location, and treatment method — are summarized in
The results of comparison between clipping and coiling are summarized in
Comparisons according to the prognosis are summarized in
Lehecka reported the results of surgical clipping for ruptured distal ACA aneurysms at his institution before the 1980’s, with surgical mortality of 1%, morbidity of 12%, and 78% of patients achieving favorable outcomes.[
Several specific features of distal ACA aneurysms — such as aneurysm location, coexisting ACA anomalies, additional aneurysms, and intracerebral hematoma — have been reported. Lehecka et al. identified the locations of 277 ruptured distal ACA aneurysms. Thirty-eight (14%) were located in the A2 segment, 244 (81%) in the A3 segment, and 15 (5%) in the A4 and A5 segments.[
The most appropriate method for treating distal ACA aneurysms remains a controversial topic.[
The previous studies have shown that the Hunt and Hess grade at admission, intracerebral hemorrhage, intraventricular hemorrhage, severe preoperative hydrocephalus, age, and rebleeding before treatment were significant predictors of poor clinical outcomes in patients undergoing either endovascular or microsurgical treatment of distal ACA aneurysms.[
Several limitations need to be considered while interpreting these results. This was a retrospective, nonrandomized, single-center study. This produced an inherent selection bias. In addition, our relatively small sample size may have generated unreliable statistically significant differences. Future, well-powered studies are necessary to further validate our results.
Although this study included many cases with poor WFNS grades, we achieved good outcomes. There were no significant between-group differences in treatment outcomes between clipping and coiling. This might be due to our center’s highly personalized process for designing each patient’s treatment plan, fundamentally coiling for infragenu aneurysms, and clipping for supragenu aneurysms. Poor WFNS grade and intracerebral hematoma appear to be risk factors for a poor prognosis in patients with ruptured distal ACA aneurysms.
1. Aboukaïs R, Zairi F, Bourgeois P, Boustia F, Leclerc X, Lejeune JP. Pericallosal aneurysm: A difficult challenge for microsurgery and endovascular treatment. Neurochirurgie. 2015. 61: 244-9
2. Carvi y Nievas MN. The influence of configuration and location of ruptured distal cerebral anterior artery aneurysms on their treatment modality and results: Analysis of our casuistry and literature review. Neurol Res. 2010. 32: 73-81
3. Cilliers K, Page BJ. Review of the anatomy of the distal anterior cerebral artery and its anomalies. Turk Neurosurg. 2016. 26: 653-61
4. de Sousa AA, Dantas FL, de Cardoso GT, Costa BS. Distal anterior cerebral artery aneurysms. Surg Neurol. 1999. 52: 128-35
5. Hui FK, Schuette AJ, Moskowitz SI, Spiotta AM, Lieber ML, Rasmussen PA. Microsurgical and endovascular management of pericallosal aneurysms. J Neurointerv Surg. 2011. 3: 319-23
6. Kawashima M, Matsushima T, Sasaki T. Surgical strategy for distal anterior cerebral artery aneurysms: Microsurgical anatomy. J Neurosurg. 2003. 99: 517-25
7. Lehecka M, Lehto H, Niemelä M, Juvela S, Dashti R, Koivisto T. Distal anterior cerebral artery aneurysms: Treatment and outcome analysis of 501 patients. Neurosurgery. 2008. 62: 590-601
8. Mann KS, Yue CP, Wong G. Aneurysms of the pericallosalcallosomarginal junction. Surg Neurol. 1984. 21: 261-6
9. McKissock W, Paine KW, Walsh LS. An analysis of the results of treatment of ruptured intracranial aneurysms, report of 772 consecutive cases. J Neurosurg. 1960. 17: 762-76
10. Menovsky T, van Rooij WJ, Sluzewski M, Wijnalda D. Coiling of ruptured pericallosal artery aneurysms. Neurosurgery. 2002. 50: 11-4
11. Ohno K, Monma S, Suzuki R, Masaoka H, Matsushima Y, Hirakawa K. Saccular aneurysms of the distal anterior cerebral artery. Neurosurgery. 1990. 27: 907-12
12. Oishi H, Nonaka S, Yamamoto M, Arai H. Feasibility and efficacy of endovascular therapy for ruptured distal anterior cerebral artery aneurysms. Neurol Med Chir (Tokyo). 2013. 53: 304-9
13. Orz Y. Surgical Strategies and outcomes for distal anterior cerebral arteries aneurysms. Asian J Neurosurg. 2011. 6: 13-7
14. Pandey A, Rosenwasser RH, Veznedaroglu E. Management of distal anterior cerebral artery aneurysms: A single institution retrospective analysis (1997-2005). Neurosurgery. 2007. 61: 909-16
15. Park KY, Kim BM, Lim YC, Chung J, Kim DJ, Joo JY. The role of endovascular treatment for ruptured distal anterior cerebral artery aneurysms: Comparison with microsurgical clipping. J Neuroimaging. 2015. 25: 81-6
16. Petr O, Coufalová L, Bradáč O, Rehwald R, Glodny B, Beneš V. Safety and efficacy of surgical and endovascular treatment for distal anterior cerebral artery aneurysms: A systematic review and meta-analysis. World Neurosurg. 2017. 100: 557-66
17. Pierot L, Boulin A, Castaings L, Rey A, Moret J. Endovascular treatment of pericallosal artery aneurysms. Neurol Res. 1996. 18: 49-53
18. Proust F, Toussaint P, Hannequin D, Rabenenoïna C, Le Gars D, Fréger P. Outcome in 43 patients with distal anterior cerebral artery aneurysms. Stroke. 1997. 28: 2405-9
19. Snyckers FD, Drake CG. Aneurysms of the distal anterior cerebral artery. A report on 24 verified cases. S Afr Med J. 1973. 47: 1787-91
20. Steven DA, Lownie SP, Ferguson GG. Aneurysms of the distal anterior cerebral artery: Results in 59 consecutively managed patients. Neurosurgery. 2007. 60: 227-33
21. 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: 2317-20
22. Suzuki S, Kurata A, Yamada M, Iwamoto K, Nakahara K, Sato K. Outcomes analysis of ruptured distal anterior cerebral artery aneurysms treated by endosaccular embolization and surgical clipping. Interv Neuroradiol. 2011. 17: 49-57
23. Waldenberger P, Petersen J, Chemelli A, Schenk C, Gruber I, Strasak A. Endovascular therapy of distal anterior cerebral artery aneurysms-an effective treatment option. Surg Neurol. 2008. 70: 368-77
24. Yamazaki T, Sonobe M, Kato N, Kasuya H, Ikeda G, Nakamura K. Endovascular coiling as the first treatment strategy for ruptured pericallosal artery aneurysms: Results, complications, and follow up. Neurol Med Chir (Tokyo). 2013. 53: 409-17
25. Yaşargil MG, Carter LP. Saccular aneurysms of the distal anterior cerebral artery. J Neurosurg. 1974. 40: 218-23