Surgical Strategy for Complex Anterior Cerebral Artery Aneurysms: Retrospective Case Series and Literature Review

• Published in: World neurosurgery Vol. 87; pp. 328 - 345
• Main Authors: Ota, Nakao, Tanikawa, Rokuya, Miyama, Masataka, Matsumoto, Takashi, Miyazaki, Takanori, Matsukawa, Hidetoshi, Yanagisawa, Takeshi, Suzuki, Go, Miyata, Shiro, Noda, Kosumo, Tsuboi, Toshiyuki, Takeda, Rihei, Kamiyama, Hiroyasu, Tokuda, Sadahisa
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.03.2016
• Subjects: Adult; Aged; Anterior Cerebral Artery - surgery; Anterior cerebral artery aneurysm; Bypass surgery; Carotid Artery, External - pathology; Carotid Artery, External - surgery; Carotid Artery, Internal - pathology; Carotid Artery, Internal - surgery; Cerebral Infarction - etiology; Cerebral Infarction - psychology; Cerebral Infarction - therapy; Cerebral Revascularization - methods; Cerebrovascular Circulation; Female; Follow-Up Studies; Humans; Intracranial Aneurysm - surgery; Intracranial Thrombosis - etiology; Intracranial Thrombosis - therapy; Male; Memory Disorders - etiology; Memory Disorders - psychology; Middle Aged; Modified Rankin Scale; Neurosurgery; Neurosurgical Procedures - methods; Postoperative Complications - psychology; Protective bypass; Retrospective Studies; Surgical strategy; Treatment Outcome; STA; Middle cerebral artery; Protective bypass; Anterior cerebral artery; Flow diverter; Modified Rankin Scale; IC; EC; ACA; Anterior communicating artery; Anterior cerebral artery aneurysm; Callosomarginal artery; MCA; AcoA; External carotid artery; Superficial temporal artery; CamA; mRS; Computed tomography angiography; CTA; Radial artery graft; Internal carotid artery; Surgical strategy; RAG; Bypass surgery; FD
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2015.10.079

Objective Giant, or complex, aneurysms of the anterior cerebral artery (ACA) are rare, but their surgical treatment is important. The authors describe their experiences with bypasses for complex ACA aneurysms and discuss the new classification of ACA bypasses, the concept of using bypasses for insurance during the approach to the aneurysm, and simplifying the surgical algorithms for these complex ACA aneurysms. Methods Over a 19-year period, 7 cases of complex ACA aneurysm were treated with bypasses and reviewed retrospectively. The bypasses were classified into 4 groups according to donor blood flow: internal carotid artery-ACA, external carotid artery-ACA, communicating bypass, and reconstruction bypass of the ipsilateral postcommunicating ACA. Results The cases included 1 precommunicating aneurysm, 3 communicating aneurysms, 2 postcommunicating aneurysms, and 1 double aneurysm (communicating and postcommunicating). The types of bypass included 1 internal carotid artery-ACA, 6 communicating bypasses, 3 external carotid artery-ACAs, and 2 reconstruction bypass of the postcommunicating ACA. Postoperative modified Rankin Scale scores were 0 (6 cases) and 3 (1 case of a communicating aneurysm with complicated memory disturbance because of infarction). One case revealed asymptomatic infarction. Conclusions Surgical treatment of complex ACA aneurysms requires knowledge of a variety of bypass techniques. Although the type of bypass should be selected according to patient-specific anatomy and the neurosurgeon’s preference, the new classification of bypass-specified ACA aneurysms may alter the way surgeons think about ACA bypasses, and in combination with the concept of the protective bypass, can be used to establish a comprehensive algorithm for each type of complex ACA aneurysm.