Treatment of a ruptured anterior communicant artery and a distal ACA aneurysm - SLICE Next Frontiers 2023 - Maria TOMBES - Jenny PANTRICS

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Anterior cerebral artery aneurysms

The anterior cerebral artery (ACA) and anterior communicating artery (Acom) are the most common location of intracranial aneurysms, accounting for a third of all ruptured aneurysms. Also, the Acom is considered the single most common site for ruptured aneurysm presenting with subarachnoid hemorrhage (SAH). Because of the complexity of anatomy and its variations in these locations, the endovascular treatment can vary from straightforward techniques as simple coiling, to advanced techniques as combined flow diverters stents, for example. [1]

In the setting of a ruptured aneurysm, the main goal is to secure the aneurysm to prevent re-bleeding, in the majority of cases it can be done with simple coiling assisted or not with balloon. Facing challenging ones, such as small aneurysms, tortuous anatomy, and high- risk bleeding aneurysms morphology, which increases the intraoperative rupture risk, other techniques should be considered. For this reason is essential to know the estimated risk of complications to decide which strategy would benefit the patient in an acute setting, also considering the skills of the operator. [2]

Complications risk

Coiling or Balloon-assisted coiling

Literature data show an overall risk of intraoperative rupture of 3.0%, reaching 3.7% in ruptured aneurysms. [2]
- This risk increases 3 times in <5mm aneurysms, and 2 times in Acom aneurysms.
- The higher risk of rupture in small aneurysms is believed to be due to the increased restriction of microcatheter movement within the aneurysm, resulting in greater stress within the aneurysm sac. [3]
- In terms of aneurysmal location higher incidence of iatrogenic rupture located in the Acom occurs because these aneurysms usually have an unfavorable dome-neck ratio and an acute angle between the internal carotid artery and the anterior cerebral artery. [3]
Thromboembolic complications related to coiling have variable risk in the literature (2-15%) [3]

Flow diverter

The literature demonstrates an overall complication rate of 17.8% (8% Ischemic vs hemorrhagic 7%) [4]
This risk is higher in different situations: [4]
- Posterior circulation (27%) when compared with anterior circulation (11.7%)
- Multiple stents 26% vs 10% in a single stent.
- Saccular 23% when compared with dissecting, fusiform, or blister aneurysm. [4]

Of note, when using a stent in the acute setting, the operator must have familiarity and knowledge with IV anti-platelet therapy to prevent stent occlusion and thromboembolic complications.

Another consideration when deciding on a flow diverter stent, depending on which device you chose, is a heavier catheter system to support stent deployment, increasing the procedure complexity.

P.S: watch the video for a very rich decision-making discussion with the experts, also an amazing discussion about IV antiplatelet use in the acute setting.

In conclusion, when dealing with an anterior cerebral artery aneurysm, mainly located in the Acom, there isn’t a treatment that fits all. We should always choose the strategy regarding cerebral artery and aneurysm anatomy, also the experience of the neuro- interventionalist performing different techniques.

Further reading

Jeong YG, Jung YT, Kim MS, Eun CK, Jang SH. Size and location of ruptured intracranial aneurysms. J Korean Neurosurg Soc. 2009;45:11–5.
Pierot L, et al. Intraoperative Complications of Endovascular Treatment of Intracranial Aneurysms with Coiling or Balloon-assisted Coiling in a Prospective Multicenter Cohort of 1088 Participants: Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) Study. Radiology. 2020 May;295(2):381-389. doi: 10.1148/radiol.2020191842.
Ihn YK, Shin SH, Baik SK, Choi IS. Complications of endovascular treatment for intracranial aneurysms: Management and prevention. Interv Neuroradiol. 2018 Jun;24(3):237-245. doi: 10.1177/1591019918758493.
Cagnazzo F, di Carlo DT, Cappucci M, Lefevre PH, Costalat V, Perrini P. Acutely Ruptured Intracranial Aneurysms Treated with Flow-Diverter Stents: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2018 Sep;39(9):1669-1675. doi: 10.3174/ajnr.A5730.