E-003 Endovascular repair of the ruptured anterior communication artery complex and wide-neck aneurysm
Authors: Lodi Y , Swrankar A , Cummins M , Sethi K , Gaylon D , Bajwa S 
Published: July 2012

Introduction

Due to the presence a complex anatomical and a hemodynamic profile at the anterior communication artery (AComA), especially when both A2 segments originate from a single A1 segment of the anterior cerebral artery, a successful surgical or endovascular repair of AComA aneurysm does not always guarantee good outcome. Surgical clipping not only poses difficulties but also may induce spasm to the anterior cerebral artery leading to stroke despite a successful procedure. Therefore, more aneurysms in AComA are being treated with endovascular technique including complex and wide neck aneurysms.

Objective

Objective of our study is to report our experiences of endovascular repair of ruptured AComA aneurysms including wide neck and complex aneurysms.

Methods

From prospectively maintained aneurysm data base consecutive patients with the diagnosis of ruptured AComA aneurysms who underwent with endovascular coiling from July 2007 to July 2009 were enrolled. Patients' demographics including Hunt and Hess (H&H) grade, fisher scale, procedure related complication and outcome were collected.

Results

54 patients with mean age of 52±14 years old were diagnosed with AComA ruptured aneurysm underwent successful endovascular repair of their aneurysm 21/54 (49% wide neck and complex) in nature. H&H V was present in 3 (5%), IV in 12 (22%), III in 16 (30%), II in 15 (28%) and I in 7 (13%). Fisher 4 was present in 25 (46%), 3 in 15 (28%), 2 in 6 (11%) and 1 in 9 (17%) of patients. 28/51 (55%) required ventriculostomy catheter 18 (35.3%) before and 10 (19.6%) after the coiling procedure. Procedure related morbidity was observed in 3/54 (5.5%) without mortality or permanent disability. Intraoperative rupture of aneurysm as manifested by the extravasations on the angiogram without any clinical manifestations (dilated pupils or increased blood pressure) was observed in two wide neck cases which resolved with subsequent coils placement. First case was a 74-years old woman who presented with H&H II and Fisher 3 and achieved GOS 5. The second case was a 46-years old woman with H&H II and Fisher 4 who achieved GOS 4. Right middle cerebral artery occlusion was observed in a 56 years old woman during coiling who presented with H&H II and Fisher 4. The MCA was completely revascularized using 2 mg TPA and MERCI retrieval device. Post procedure examination was non-focal and achieved GOS 5 in 30 days. Complete obliteration of aneurysms was observed in 31 (57%) and near complete in 21 (39%) and subtotal in two cases (4%). 30 days good outcome was observed in 72% of cases (GOS 5 in 27 (50%), GOS 4 in 12 (22%), GOS 3 in 8 (15%) and poor outcome GOS 1 (dead) in 7 (13%). Poor outcome and disabilities was associated with high H&H grade.

Conclusions

Endovascular coiling to repair ruptured AComA could be offered in most of the cases including those with wide neck and complex in nature. The most common but challenges are intraoperative rupture of aneurysm and thromboembolic event, which could be successfully treated with good outcome.

Competing interests

None.