| BackgroundSpontaneous subarachnoid hemorrhage is a common cerebral vascular disease which can lead to disability or even death. As we all known, intracranial aneurysm rupture is the most common cause of subarachnoid hemorrhage (SAH). Some studies indicate that aneurysms of the anterior communicating artery account for 30%-37% of intracranial aneurysms. Anterior communicating artery aneurysm(AACA) is located between the both sides of the anterior cerebral artery, which often has lots of perforating arteries and the extremely complex anatomical relationship with surrounding brain tissue. Therefore require a higher surgical sticks and complications after surgery. Many neurosurgeons feel competent clipping anterior communicating artery (ACoA)aneurysms and include this lesion in their practice. However, endovascular therapy removes simple aneurysms that would have been easiest to clip with the best results. What remains are aneurysms with complex anatomy and technical challenges that are not well described.OBJECTIVEA contemporary surgical series with ACoA aneurysms is reviewed to define the patients, microsurgical techniques, and outcomes in current practice in the Endovascular EraMaterials and Methods1.Research Subjects:We collected 168 patients (age 20-82 years, mean 52.1 years) undergoing coil embolization or for anterior communicating artery aneurysms from January 2007 to December 2013.A female preponderance was observed, with 102 women (60.7%) and 66 men (39.3%). Most patients presented with subarachnoid hemorrhage (n= 126,75.0%). Hunt-Hess grade 1 was the most common grade (n= 40,31.7%), followed in order of descending frequency, by grade 3 (n= 34,26.8%), grade 4 (n= 27,21.3%), grade 2 (n= 19,15.2%), and grade5 (n= 6,4.9%). Other aneurysms were unruptured (n = 42,24.8%),diagnosed in association with decreased vision during the evaluation of headache or other symptoms or after head trauma (n= 4,2.3%).2.Methods:The detailed implementation methods, benefits and risks of surgical clipping and endovascular embolization were informed to patients’ relatives. Among the 168 patients with AACA,92 were embolized with coils and 76 received the surgical clipping.Through research analysis, complexities influencing aneurysm management included (1) adherence of wear vascular (2) resection of frontal gyrus rectus; (3) previous coiling; (4) the diameter length of aneurysm’s neck; (5) the classification of aneurysms; (6) intraoperative aneurysm rupture; (7) complex clipping; and (8) atherosclerotic calcification.ResultsSimple ACoA aneurysms were encountered in 91 patients (54.2%) and complex neurysms in 77 (45.8%). Expose of ACoA and intraoperative rupture were the most common complexities. Simple aneurysms had favorable outcomes in 86.6% of patients, whereas aneurysms with 1 or multiple complexities had favorable outcomes in 78.2% and 75.0%, respectively. Intraoperative rupture (P<0.01),wide-necked aneurysms (P= 0.04), lobulated aneurysm(P=0.05) and complex clipping (P=0.05) were associated with increased neurological worsening.ConclusionBecause endovascular therapy alters the surgical population, neurosurgeons should ecalibrate their expectations with this once straightforward aneurysm. The current mix of AcoA neurysms requires advanced techniques including frontal lobe resection straight back, AChA microdissection, complex clipping, and facility with intraoperative rupture. Microsurgery is recommended for recurrent aneurysms after coiling, complex branches, aneurysms causing oculomotor nerve palsy, multiple aneurysms, and patients with hematomas. |
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