An Aggressive Management of Anterior Communicating Artery Aneurysms: Predictive Outcome Factors

• Published in: Journal of Neurological Surgery Part A: Central European Neurosurgery
• Main Authors: Ciurea, A. V., Munteanu, V., Nica, D. A., Mohan, A., Moisa, H.
• Format: Conference Proceeding
• Language: English
• Published: 19.10.2015
• ISSN: 2193-6315; 2193-6323
• DOI: 10.1055/s-0035-1566326

Background Intracranial aneurysms (IA) have a prevalence rate between 0.2 and 7.9% in the literature. Material and Methods The authors present a study performed on ∼668 consecutively operated patients with intracranial aneurysms, operated between January 1998 and December 2014, a time span of 17 years. There were 46 children (7.5%) and 622 adults (92.5%). The localization of intracranial aneurysms involved the anterior communicating artery (AComA) in 182 cases (27.24%), the middle cerebral artery in 155 cases (23.2%), the posterior communicating artery in 108 cases (16.16%), the internal carotid artery in 87 cases (13.02%), the pericallosal artery in 7 cases (1.04%), the basilar artery in 20 cases (3%), and vertebral artery in 11 cases (1.64%). Multiple aneurysms represent in our data 91 cases (13.62%). Regarding the patients with AComA aneurysms, most of them were between 41 and 50 years old (83 patients; 45.6%). Male was the preponderant sex (124 patients; 68%) (with a male to female ratio of 1.46: 1). The symptoms were dominated by headache (178 patients; 98%), neck stiffness (171 patients; 94%), focal neurologic deficits (129 patients; 71%), seizures (95 patients; 52%), etc. Most patients were Hunt and Hess (H&H) grade II (93 patients; 51.2%), H&H grade III (38 patients; 21.1%) and H&H grade I (35 patients; 19.5%) at admission. There were 14 (7.7%) difficult cases in H&H IV and no cases operated in H&H V. The patients' associated pathology included systemic arterial hypertension (136 cases; 75%), obesity/hypercholesterolemia (62 cases; 34%), ischemic cardiopathy (29 cases; 15.9%), diabetes mellitus (27 cases; 15.1%), chronic alcoholism (16 cases; 9%), ischemic stroke (16 cases; 9%), atrial fibrillation (13 cases, 7%), and miscellaneous (26 cases; 14.1%) (e.g., anticoagulant therapy). The main investigation methods for our patients were CT scan or DS angiography. Currently, the most important methods are 3D DS angiography and 3D CT angiography. All cases were operated as soon as possible after SAH and diagnosis. “Early surgery” eliminates the risk of rebleeding and facilities the treatment of vasospasm. The authors present a management strategy which is based on early microsurgical clipping, vasospasm prevention, and adequate neuroprotection and neurorehabilitation. The Extended Glasgow Outcome Scale (GOS-EX) in our data at 6 months postoperative shows upper good recovery in 52 cases (28.44%), lower good recovery in 51 cases (28.29%), upper moderate disability in 33 cases (18.26%), lower moderate disability in 28 cases (15.26%), upper severe disability in 5 cases (2.84%), lower severe disability in 4 cases (1.94%), vegetative state in 2 cases (1.04%), and death in 7 cases (3.89%). We also used the Rankin modified scale in global outcome. Conclusions Anterior communicating artery aneurysms are important neurosurgical challenges as ruptures and complications are life-threatening issues. The timing of the surgical intervention is the key to avoid life-threatening complications. Under these circumstances, admission and diagnosis must be performed as extremely fast as possible and surgery must be performed as soon as possible. Therefore, an aggressive treatment is mandatory to obliterate an aneurysm. Keywords intracranial aneurysm; anterior communicating artery; subarachnoid hemorrhage (SAH); Hunt and Hess scale (H&H); 3D CT angiography; microsurgery