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Analysis of superiorly projecting anterior communicating artery aneurysms: anatomy, techniques, and outcome. A proposed classification system

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Abstract

Superiorly projecting (SP) anterior communicating artery (AComA) aneurysms are typically described as a homogenous group. Clinically and microsurgically, these aneurysms vary in multiple important characteristics. We propose a microsurgical classification system for these complex aneurysms and review its implications regarding presentation, microsurgical techniques, and outcome. This retrospective analysis reviews patients undergoing clipping of SP AComA aneurysms (2005–2013). The classification system is based on the virtual plane created by the A2 segments and its relationship to the aneurysm. Aneurysm type was assessed by intraoperative images and videos. Type 1 is defined by bisection of the dome by the virtual plane. Type 2 is defined by dome projection posterior to this plane. Sagittal rotation of the plane defines type 3. We analyzed clinical presentation, morphology, angiographic characteristics, operative technique, and outcome relative to the classification types. There were 44 SP AComA aneurysms. 3D angiographic images predicted classification type in 83 %. Type 1 presented more often with SAH (95.5 %, p = 0.0046). There was no statistically significant difference between the types regarding patient demographics or aneurysm characteristics. In type 2, fenestrated clips were used frequently (87.5 % p= 0.0016), and there was higher rate of intraoperative rupture (37.5 %). Although there was no statistically significant difference between the types in respect to HH grade upon presentation, patients with type 2 aneurysms experienced higher rates of poor GOS (50 %). The proposed classification system for SP AComA aneurysms has implications regarding surgical planning, micro-dissection, clipping, and outcome. Type 2 aneurysms carry significant surgical risk.

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Acknowledgments

The authors wish to thank Nina Kohn for biostatistics assistance and Karen Black M.D. for imaging assistance.

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Authors and Affiliations

  1. Division of Neurosurgery, Maimonides Medical Center, Brooklyn, NY, USA

    Erez Nossek

  2. Department of Neurosurgery, Hofstra North Shore–Long Island Jewish School of Medicine and North Shore–Long Island Jewish Health System, 300 Community Drive, 9 Tower, Manhasset, NY, 11030, USA

    Avi Setton, Reza Karimi, Amir R. Dehdashti, David J. Langer & David J. Chalif

  3. Department of Neurosurgery, North Shore-Long Island Jewish Health System, Lenox-Hill Hospital, New York, NY, USA

    David J. Langer

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  1. Erez Nossek
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  2. Avi Setton
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  3. Reza Karimi
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  4. Amir R. Dehdashti
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  5. David J. Langer
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  6. David J. Chalif
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Correspondence to David J. Chalif.

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Comments

Akitsugu Kawashima, Chiba, Japan

This article described the proposal of the new classification system for superior projecting (SP) anterior communicating artery (AcomA) aneurysms which is based on the virtual plane created by the A2 segments and its relationship to the aneurysm dome. The virtual plane can shift in a coronal/axial projection and in a sagittal alignment, which is the strong point of the article and difference from the classical classification system. The authors concluded this system helps surgeons understand anatomical characteristics of SP AcomA AN and makes efficacious strategy. And they also emphasized usefulness of fenestrate clip for all sized aneurysms with superior direction. I support the new classification system; however, I disagree frequent use of fenestrate clip in this series which included mainly small aneurysm cases compared with previous report.1 From the rate of postoperative ischemic changes per CT, it is hardly to say that fenestrated clips should be used so frequently for the SP AComA aneurysms. A single straight clip first is recommended by experts,2, 3 and in some circumstance, fenestrated clips may be provided especially for large size aneurysms.3 Better view of structures around the aneurysm could be achieved by coagulating and reshaping the dome after applying temporary clips on the both A1s and placing pilot clip with small resection of the gyrus rectus in many cases.2

References

1. Zada G, Christian E, Liu CY, Giannotta SL. Fenestrated aneurysm clips in the surgical management of anterior communicating artery aneurysms: Operative techniques and strategy. Clinical article. Neurosurgical focus. 2009;26:E7

2. Hernesniemi J, Dashti R, Lehecka M, Niemela M, Rinne J, Lehto H, et al. Microneurosurgical management of anterior communicating artery aneurysms. Surgical neurology. 2008;70:8–28; discussion 29

3. Riina HA, Lemole GM, Jr., Spetzler RF. Anterior communicating artery aneurysms. Neurosurgery. 2002;51:993–996; discussion 996

Kazuhiro Hongo, Matsumoto, Japan

This is a paper reporting retrospective analysis of 44 patients with anterior communicating artery (AComA) aneurysm projecting superiorly (SP). They proposed new classification of SP AComA aneurysm based on angioarchitecture of the bilateral A2 arteries. They concluded that type 2 aneurysms, in which domes were oriented posterior to the virtual proximal A2 segment plane, yet remain completely within the superior projection quadrant, had a surgical risk.

The authors nicely analyzed the surgical cases, and they proposed new classification system. The SP AComA aneurysms are relatively difficult to clip especially in the standard pterional approach. They raised the important issue. At surgery for a SP AComA aneurysm via the pterional approach, adequate dissection of the interhemispheric fissure is necessary as the authors may apply this technique, although the surgical procedure on this point has not been described in detail. Especially for the type 2 aneurysm, adequate dissection of the interhemispheric fissure is needed to expose the aneurysm neck and to visualize the hypothalamic artery. With the usual pterional approach, the hypothalamic artery is not visible.

Another surgical option is the interhemispheric approach. Of course, the selection of the surgical approach is highly based on the surgeon’s preference. The type 2 AComA aneurysm can be a good indication for the interhemispheric approach.

In any way, the authors focused the SP AComA aneurysm with proposing the new classification. The authors are to be congratulatory. With having this issue in mind, the surgical result of the SP AComA aneurysm can be better.

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Nossek, E., Setton, A., Karimi, R. et al. Analysis of superiorly projecting anterior communicating artery aneurysms: anatomy, techniques, and outcome. A proposed classification system. Neurosurg Rev 39, 225–235 (2016). https://doi.org/10.1007/s10143-015-0677-4

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  • DOI: https://doi.org/10.1007/s10143-015-0677-4

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