Aneurysm management: Complex ACA aneurysm management

There is no tiny doubt that hard challenges are mostly faced while managing Anterior cerebral and basilar arterial aneurysms. SLICE 2024 platform, as every event, welcomed different world experts to investigate the management`s algorithm deeply by discussing three successive diverse complex cases. Till the current moment, variable strategies were proposed through the literature, however, they are still case-based and under negotiation. Due to rapidly rising innovative techniques and tools, it is a difficult mission to establish completely satisfactory clear guidelines to manage such cases. SLICE ACCEPTS CHALLENGE!!

First case: Acom Aneurysm 

A 77-year-old female patient presented with incidental ACA/ACOM aneurysm of complex saccular wide neck shape with 7 mm size. Risk factors were obesity, smoking, and hypertension.

✓ How could we approach such a patient?! The panel discussed several strategies……! 

- Single or double bilateral Stent assisted coiling.

- Bilateral separated or X-shaped flow diverters ± coiling.

- Web device direct deployment.

✓ The discussion was on fire!!! What are the differences between each?!

The first option was an accepted method of management, although putting the patient on long-term antiplatelets was the factor that excluded this choice as a first option. A further reason was in favor of using single stent for economic purposes.

The second option was recommended as an efficient single-step procedure, however, the risk of ischemic post-procedural hazards after flow diverters was the issue. It was mentioned in the literature that the risk of ischemia can occur in about 2% of cases, especially in the artery of Huebner in our case.

The third option was chosen because it is a one-step technique, with no need for long-term antiplatelets, and its efficiency in wide-neck aneurysms was proved in the literature. But no one can deny the risk of not fully occluding the neck and deficient wall apposition. However, if any further management technique is required, it will not be hard after the web device.

✓ Choosing the perfect Web device!! Some recommendations were agreed upon!! 

- Assessment accurately shape, size, height, and diameter (Dimensions).

- Using simulation software (on the 3D reconstructed images which helps to not only choose the best strategy and materials sizes but also roughly expect outcomes).

- Charts recommended from the manufacturer could be considered.

Second case: A1 Aneurysm 

A 47-year-old female smoker patient presented with an incidental A1 aneurysm of saccular shape with 4 mm size. It is worth mentioning that there was an MCA accessory perforator arising from the neck.

✓ The approach was again debated!! Three were suggested…. 

- Direct web device.

- Double or single catheter simple coiling.

- Balloon-assisted coiling.

✓ The options were more direct and limited this time!! Web device or coiling?! 

It was discussed that a higher risk of complications is expected during the coiling of aneurysms of size less than 4 mm. Additionally, Stenting was another suggestion but can face some difficulties regarding the anatomical curves. Moreover, simple coiling was expected to encounter instability of the whole system to deliver the coils. Thus, balloon-assisted coiling was suggested eventually. Although, it was mentioned in the literature that using a balloon can increase the risk of rupture, but not in all cases.

✓ The operation went so smoothly, but suddenly!! A single herniated coil from the sac was noticed?! Should we fear?! Not really if not needed. The panel reassured….

They recommended first to wait for 10 or 15 minutes then do a run and evaluate and ensure the coil stability with no movement or migration. If so, then the patient is only managed by prescribing double antiplatelet for 3 months. This solution was mentioned to be better than putting a stent and leaving metal behind more than the herniated single coil.

Third case: Giant latero-basilar Aneurysm

A 57-year-old female patient presented with an incidental giant left PCA and superior cerebellar artery (SCA) aneurysm of saccular shape with a 15 mm size. Risk factors were smoking, obesity, hypertension, COPD, and laryngeal tumor. It is worth mentioning that there were contributors of left SCA, right SCA, P1, and P2. TOO COMPLEX!!! isn`t it?! How TO APPROACH?!

✓ Coiling alone was almost totally excluded as an effective strategy! Is there another?! 

- Flow diverter between P2 and basilary could be an option + sac packing either by coiling or web device to avoid post-procedure rupture.

✓ A lot of highly professional techniques and tricks were explained and suggested by the experts. One of them was moving and pulling an undeployed opened web device to change the position of the wire to reach the aimed vessel if catheterization was difficult. Another was using two web devices at the same time. MARVELOUS!!

Generally, some considerations were provided to be the basis of choosing which best strategy to follow:

- Patient`s condition, aneurysmal state (Ruptured or not), and procedure status itself (Elective or emergent

- The expertise and materials availability.

- Technical and anatomical challenges of vessels and aneurysms.

The article only mentioned the session`s highlights. However, technical, practical, and fruitful tips and high clinical experiences were clarified and discussed in detail to solve and overcome technical and anatomical challenges. Don`t miss watching the episodes!!