Advertisement

Neurosurgical Review

, Volume 39, Issue 2, pp 225–235 | Cite as

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

  • Erez Nossek
  • Avi Setton
  • Reza Karimi
  • Amir R. Dehdashti
  • David J. Langer
  • David J. Chalif
Original Article

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.

Keywords

Anterior communicating artery Aneurysm Classification Microsurgery Superiorly projecting Clip 

Notes

Acknowledgments

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

References

  1. 1.
    Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R, International Subarachnoid Aneurysm Trial Collaborative G (2002) International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274CrossRefPubMedGoogle Scholar
  2. 2.
    Sekhar LN, Natarajan SK, Britz GW, Ghodke B (2007) Microsurgical management of anterior communicating artery aneurysms. Neurosurgery 61:273–290, discussion 290–272PubMedGoogle Scholar
  3. 3.
    Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, Nakaji P, Wallace RC (2013) The barrow ruptured aneurysm trial: 3-year results. J Neurosurg 119:146–157CrossRefPubMedGoogle Scholar
  4. 4.
    Yasargil M (1984) Microneurosurgery: In 4 volumes. vol II. Thieme New york, pp 180–185Google Scholar
  5. 5.
    Hernesniemi J, Dashti R, Lehecka M, Niemela M, Rinne J, Lehto H, Ronkainen A, Koivisto T, Jaaskelainen JE (2008) Microneurosurgical management of anterior communicating artery aneurysms. Surg Neurol 70:8–28, discussion 29CrossRefPubMedGoogle Scholar
  6. 6.
    Rhoton AL Jr (2002) The supratentorial arteries. Neurosurgery 51:S53–S120PubMedGoogle Scholar
  7. 7.
    Lawton M (2011) Seven aneurysms: tenets and techniques for clipping. Thieme, NYCrossRefGoogle Scholar
  8. 8.
    Matsukawa H, Uemura A, Fujii M, Kamo M, Takahashi O, Sumiyoshi S (2013) Morphological and clinical risk factors for the rupture of anterior communicating artery aneurysms. J Neurosurg 118:978–983CrossRefPubMedGoogle Scholar
  9. 9.
    Proust F, Debono B, Hannequin D, Gerardin E, Clavier E, Langlois O, Freger P (2003) Treatment of anterior communicating artery aneurysms: complementary aspects of microsurgical and endovascular procedures. J Neurosurg 99:3–14CrossRefPubMedGoogle Scholar
  10. 10.
    Solomon RA (2001) Anterior communicating artery aneurysms. Neurosurgery 48:119–123PubMedGoogle Scholar
  11. 11.
    Hyun SJ, Hong SC, Kim JS (2010) Side selection of the pterional approach for superiorly projecting anterior communicating artery aneurysms. J Clin Neurosci 17:592–596CrossRefPubMedGoogle Scholar
  12. 12.
    Gonzalez N, Sedrak M, Martin N, Vinuela F (2008) Impact of anatomic features in the endovascular embolization of 181 anterior communicating artery aneurysms. Stroke 39:2776–2782CrossRefPubMedGoogle Scholar
  13. 13.
    Riina HA, Lemole GM Jr, Spetzler RF (2002) Anterior communicating artery aneurysms. Neurosurgery 51:993–996, discussion 996PubMedGoogle Scholar
  14. 14.
    Taschner CA, Thines L, Lernout M, Lejeune JP, Leclerc X (2007) Treatment decision in ruptured intracranial aneurysms: comparison between multi-detector row CT angiography and digital subtraction angiography. J Neuroradiol Journal de neuroradiologie 34:243–249CrossRefPubMedGoogle Scholar
  15. 15.
    Zada G, Christian E, Liu CY, Giannotta SL (2009) Fenestrated aneurysm clips in the surgical management of anterior communicating artery aneurysms: operative techniques and strategy. Clinical article. Neurosurg Focus 26, E7CrossRefPubMedGoogle Scholar
  16. 16.
    Elijovich L, Higashida RT, Lawton MT, Duckwiler G, Giannotta S, Johnston SC, Cerebral Aneurysm Rerupture After Treatment I (2008) Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study. Stroke 39:1501–1506CrossRefPubMedGoogle Scholar
  17. 17.
    Lawton MT, Du R (2005) Effect of the neurosurgeon’s surgical experience on outcomes from intraoperative aneurysmal rupture. Neurosurgery 57:9–15, discussion 19–15CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Erez Nossek
    • 1
  • Avi Setton
    • 2
  • Reza Karimi
    • 2
  • Amir R. Dehdashti
    • 2
  • David J. Langer
    • 2
    • 3
  • David J. Chalif
    • 2
  1. 1.Division of NeurosurgeryMaimonides Medical CenterBrooklynUSA
  2. 2.Department of NeurosurgeryHofstra North Shore–Long Island Jewish School of Medicine and North Shore–Long Island Jewish Health SystemManhassetUSA
  3. 3.Department of NeurosurgeryNorth Shore-Long Island Jewish Health System, Lenox-Hill HospitalNew YorkUSA

Personalised recommendations