Frequently it is a wide necked aneurysm with an irregular shape, incorporate parent vessels, and are associated with significant variations in vascular anatomy.
The most common site of rupture of very small intracranial aneurysms was the anterior communicating artery (ACoA). Rupture of small and very small aneurysms is unpredictable, and treatment may be considered in selected high-risk patients according to factors such as young age, ACoA location, and hypertension 4).
Anterior communicating artery aneurysms frequently present wide aneurysm necks and incorporate parent vessels. They are associated with significant variations in vascular anatomy, especially hypoplasia or aplasia of one of the proximal anterior cerebral artery.
Morphological Scoring System of Choi
Very small intracranial aneurysm (< 3 mm)
Small intracranial aneurysm (< 5 mm)
Medium sized intracranial aneurysm (5-9.9 mm)
Large or Giant intracranial aneurysm (> 10 mm)
Chen et al., classified as Type I, II (IIa, IIb), III and IV, based on the various projections and size of aneurysm. The principle for the choice of operative side was designed based on the type of aneurysm and the A2 fork orientation (the interrelations between the plane of bilateral A2, AComA, and mid-saggital plane) 7).
Small aneurysms located at the anterior communicating artery carry significant procedural challenges due to a complex anatomy.
Inferior or downward direction
Posterior or backward direction
Giant anterior communicating artery aneurysms are rare.
In clinic, it’s very common to find out the unequal development of section A1 of anteromedial brain artery. The resulting hemodynamic changes are considered to be one of the main reasons for the formation of anterior communicating artery aneurysms 8).
Vascular imaging was evaluated with 3D Slicer© to generate models of the aneurysms and surrounding vasculature. Morphological parameters were examined using univariate and multivariate analysis and included aneurysm volume, aspect ratio, size ratio, distance to bifurcation, aneurysm angle, vessel angle, flow angle, and parent-daughter angle. Multivariate logistic regression revealed that size ratio, flow angle, and parent-daughter angle were associated with aneurysm rupture after adjustment for age, sex, smoking history, and other clinical risk factors. Simple morphological parameters such as size ratio, flow angle, and parent-daughter angle may thus aid in the evaluation of rupture risk of anterior communicating artery aneurysms 9).
These aneurysms are usually silent until they rupture.
Suprachiasmatic pressure may cause altitudinal visual field deficits, abulia or akinetic mutism, amnestic syndromes, or hypothalamic dysfunction.
Giant AComA aneurysms are extremely rare and may present with vision loss 11).
Visual apparatus compression can occur from giant AComA aneurysm directed posteriorly and inferiorly 12).
The pattern of visual loss in these cases is variable. The common pattern of visual loss is bilateral field deficits.
The other patterns of visual loss due to AComA aneurysms are central scotoma, bilateral heteronymous deficits, monocular or binocular inferior field loss, asymmetrical bitemporal hemianopsia, and incongruous homonymous hemianopsia 13).
Weisberg reviewed the CT findings in 40 patients with ruptured aneurysms of the anterior cerebral or anterior communicating arteries. Within 3 days of the ictus, the common patterns included blood in the pericallosal cistern and interhemispheric fissure, blood in the caval-septal region, unilateral or bilateral frontal hematoma, and diffuse symmetric intraventricular and basal cisternal blood 14).
For CT classification see the Modified Fisher scale.
Endovascular coiling (EC) resulted in a more favorable clinical outcome, and microsurgical clipping (MC) resulted in more robust aneurysm repair, for unruptured ACoA aneurysms. Stent assisted coiling (SAC) had a higher treatment morbidity risk than EC, without reduction in retreatment rate. All treatments were effective in preventing SAH. The current pooled analysis of treatment outcomes provides a useful aid to pretreatment clinical decision making 15).
In a retrospective follow-up study covering a time period of four years 18 patients operated upon early for an aneurysm of the anterior communicating artery (ACoA) and a control group of 21 patients with aneurysmal subarachnoid haemorrhage (SAH) from other sources than ACoA aneurysm and 9 patients with SAH of nonaneurysmal origin were subjected to neuropsychological examination. Both groups were comparable in their neurological condition on admission and in the severity of bleeding seen on CT-scan. Testing included memory functions, concentration, logical and spatial thinking, a Stroop-test, an aphasia screening test and a complex choice reaction task. Patients with SAH of a ruptured ACoA aneurysm did not differ significantly from the control group in any of the tests used. But there was a trend for the ACoA patients to have more memory problems than the patients with SAH of other origins. On the other hand the patients in the control group with aneurysmal SAH of other locations and with non-aneurysmal SAH had not significantly more problems with concentration and aphasia than the patients with ruptured ACoA aneurysm. These results, which differ from the common opinion of frequent occurrence of memory deficits in ACoA aneurysms are interpreted as a consequence of the changes in improved pre-, intra- and postoperative management in modern neurosurgery 16).
Digital subtraction angiography images were reviewed for 204 patients with either a ruptured or an unruptured ACoA aneurysm. The ratio of the width of the larger A1 segment of the anterior cerebral artery to the smaller A1 segment was calculated. Patients with an A1 ratio greater than 2 were categorized as having A1 segment hypoplasia. The relationship of A1 segment hypoplasia to both patient and aneurysm characteristics was then assessed.
Of 204 patients that presented with an ACoA aneurysm, 34 (16.7%) were found to have a hypoplastic A1. Patients with A1 segment hypoplasia were less likely to have a history of smoking (44.1% vs 62.9%, p = 0.0410). ACoA aneurysms occurring in the setting of a hypoplastic A1 were also found to have a larger maximum diameter (mean 7.7 vs 6.0 mm, p = 0.0084). When considered as a continuous variable, increasing A1 ratio was associated with decreasing aneurysm dome-to-neck ratio (p = 0.0289). There was no significant difference in the prevalence of A1 segment hypoplasia between ruptured and unruptured aneurysms (18.9% vs 10.7%; p = 0.1605).
The results suggest that a hypoplastic A1 may affect the morphology of ACoA aneurysms. In addition, the relative lack of traditional risk factors for aneurysm formation in patients with A1 segment hypoplasia argues for the importance of hemodynamic factors in the formation of ACoA aneurysms in this anatomical setting 17).
Between January 2008 and May 2016, information on 179 consecutive patients with unruptured AcoA aneurysms was obtained and included demographic data, aneurysm features, risk factors for formation and rupture, treatment type, complications, and follow-up information. A 2-tailed t test was used for continuous data and the chi-square test for categorical variables. Statistical significance was set at P value < 0.05.
There were 76 patients 65 and older (42.5%) and 103 younger than 65 (57.5%). Conservative management was more common in older patients (67.1% vs 41.7%, P=0.001). Endovascular treatment was more commonly used in the older population (80% vs 61% of the treated aneurysms in older and younger group, P=0.16). Treatment-related complications were 8% but resulted in permanent neurological deficits in one patient (1.2%). Among conservatively treated aneurysms, three (3.2%) ruptured at follow-up resulting in patient death in two cases (2.4%). All three ruptures occurred in elderly patients.
With a modern approach that emphasizes endovascular therapy, especially in older individuals, unruptured AcoA aneurysms can be treated with a very low morbidity. Among patients with small aneurysms for which treatment was not deemed indicated or necessary, the rate of rupture at follow-up was not negligible, with 5.8% of older patients experiencing bleeding from the aneurysm 18).
Colby et al., retrospectively reviewed an IRB-approved database of patients with an aneurysm at a single institution for patients with ACoA or A1-A2 aneurysms treated with PED. Data analyzed included demographics, aneurysm characteristics, procedural details, follow-up results, and outcomes.
A total of 50 procedures were performed on 41 patients, including seven patients who underwent bilateral ‘H-pipe’ PED placement. The average age was 56 years and 46% of the patients were female. The average aneurysm size was 4.5 mm, and two large (>10 mm) aneurysms were treated. The vessel of origin was either the ACoA (26 aneurysms, 63%) or the A1-A2 junction (15 aneurysms, 37%). Eighteen patients (44%) had prior subarachnoid hemorrhage and 20 had previously been treated either with clipping (6 aneurysms, 15%) or coiling (14 aneurysms, 34%). Procedural success was achieved in 48/50 cases (96%) and two cases were aborted. Coils were deployed adjunctively in two cases (4%). Procedural outcomes included no deaths, one major ischemic stroke (2%), and two patients with intracranial hemorrhage (4%). Complete aneurysm occlusion was achieved in 81% of patients at 6 months and 85% of patients at last follow-up digital subtraction angiography.
The PED can be used safely and effectively in the treatment of aneurysms of the ACoA region. This represents a good alternative treatment option to microsurgical clipping and endovascular coiling 19).
A prospectively maintained single-institution neuroendovascular database was accessed to identify consecutive cases of very small (<3 mm) ruptured anterior communicating artery aneurysms treated endovascularly between 2006 and 2013.
A total of 20 patients with ruptured very small (<3 mm) anterior communicating artery aneurysms were consecutively treated with coil embolization. The average maximum diameter was 2.66 ± 0.41 mm. Complete aneurysm occlusion was achieved for 17 (85%) aneurysms and near-complete aneurysm occlusion for 3 (15%) aneurysms. Intraoperative perforation was seen in 2 (10%) patients without any clinical worsening or need for an external ventricular drain. A thromboembolic event occurred in 1 (5 %) patient without clinical worsening or radiologic infarct. Median clinical follow-up was 12 (±14.1) months and median imaging follow-up was 12 (±18.4) months.
This report describes the largest series of consecutive endovascular treatments of ruptured very small anterior communicating artery aneurysms. These findings suggest that coil embolization of very small aneurysms in this location can be performed with acceptable rates of complications and recanalization 20).
Between January 2008 and February 2015, 254 consecutive patients with 255 ACoA aneurysms were treated with coiling. We retrospectively reviewed intraoperative angiograms and medical records to identify intraprocedural rupture and thrombus formation, and re-measured aneurysm morphologies using CT angiography images. Multivariate logistic regression models were used to determine independent predictors of intraprocedural rupture and thrombus formation.
Of the 231 patients included, intraprocedural rupture occurred in 10 (4.3%) patients, and thrombus formation occurred in 15 (6.5%) patients. Patients with smaller aneurysms more often experienced intraprocedural rupture than those with larger aneurysms (3.5±1.3 mm vs 5.7±2.3 mm). Multivariate analysis showed that smaller ruptured aneurysms (p=0.003) were independently associated with intraprocedural rupture. The threshold of aneurysm size separating rupture and non-rupture groups was 3.5 mm. Multivariate analysis showed that a history of hypertension (p=0.033), aneurysm neck size (p=0.004), and parent vessel angle (p=0.023) were independent predictors of thrombus formation. The threshold of parent vessel angle separating thrombus and non-thrombus groups was 60.0°.
Ruptured aneurysms <3.5 mm were associated with an increased risk of intraprocedural rupture, and parent vessel angle <60.0°, wider-neck aneurysms, and a history of hypertension were associated with increased risk of thrombus formation during coiling of ruptured ACoA aneurysms21).
In 33 cases among 351 cases of ruptured anterior communicating artery aneurysms treated surgically, from 1991 to 2000, the dome of aneurysm was compressed in optic pathway. In some cases, aneurysm impacted into the optic nerve that deep hollowness was found when the aneurysm sac was removed during operation. Among 33 cases, 10 cases presented with preoperative visual symptoms, such as visual dimness (5), unilateral visual field defect (2) or unilateral visual loss (3), 20 cases had no visual symptoms. Visual symptoms could not be checked in 3 cases due to the poor mental state. In 6 cases among 20 cases having no visual symptoms, optic nerve was deeply compressed by the dome of aneurysm which was seen in the surgical field. Of 10 patients who had visual symptoms, 8 showed improvement in visual symptoms within 6 months after clipping of aneurysms. In 2 cases, the visual symptoms did not recover.
Anterior communicating artery aneurysm can cause visual symptoms by compressing the optic nerve or direct rupture to the optic nerve with focal hematoma formation. Park et al., emphasize that cerebral vascular study is highly recommended to detect intracranial aneurysm before its rupture in the case of normal CT findings with visual symptoms and frequent headache 22).
A prospective study included 223 patients who were divided into three groups: Group A (83 microsurgically treated patients, 1990-1995); Group B (103 microsurgically treated patients, 1996-2000); and Group C (37 patients treated with Guglielmi Detachable Coil [GDC] embolization, 1996-2000). Depending on the direction in which the aneurysm fundus projected, the authors attempted to apply microsurgical treatment to Type 1 aneurysms (located in front of the axis formed by the pericallosal arteries). They proposed the most adapted procedure for Type 2 aneurysms (located behind the axis of the pericallosal arteries) after discussion with the neurovascular team, depending on the physiological status of the patient, the treatment risk, and the size of the aneurysm neck. In accordance with the classification of Hunt and Hess, the authors designated those patients with unruptured aneurysms (Grade 0) and some patients with ruptured aneurysms (Grades I-III) as having good preoperative grades. Patients with Grade IV or V hemorrhages were designated as having poor preoperative grades. By performing routine angiography and computerized tomography scanning, the causes of unfavorable outcome (Glasgow Outcome Scale [GOS] score < 5) and the morphological results (complete or incomplete occlusion) were analyzed. Overall, the clinical outcome was excellent (GOS Score 5) in 65% of patients, good (GOS Score 4) in 9.4%, fair (GOS Score 3) in 11.6%, poor (GOS Score 2) in 3.6%, and fatal in 10.3% (GOS Score 1). Among 166 patients in good preoperative grades, an excellent outcome was observed in 134 patients (80.7%). The combined permanent morbidity and mortality rate accounted for up to 19.3% of patients. The rates of permanent morbidity and death that were related to the initial subarachnoid hemorrhage were 6.2 and 1.5% for Group A, 6.6 and 1.3% for Group B, and 4 and 4% for Group C, respectively. The rates of permanent morbidity and death that were related to the procedure were 15.4 and 1.5% for Group A, 3.9 and 0% for Group B, and 8 and 8% for Group C, respectively. When microsurgical periods were compared, the rate of permanent morbidity or death related to microsurgical complications decreased significantly (Group A, 11 patients [16.9%] and Group B, three patients [3.9%]); Fisher exact test, p = 0.011) from the period of 1990 to 1995 to the period of 1996 to 2000. The combined rate of morbidity and mortality that was related to the endovascular procedure (16%) explained the nonsignificance of the different rates of procedural complications for the two periods, despite the significant decrease in the number of microsurgical complications. Among 57 patients in poor preoperative grade, an excellent outcome was observed in 11 patients (19.3%); however, permanent morbidity (GOS Scores 2-4) or death (GOS Score 1) occurred in 46 patients (80.7%). With regard to the correlation between vessel occlusion (the primary microsurgical complication) and the morphological characteristics of aneurysms, only the direction in which the fundus projected appeared significant as a risk factor for the microsurgically treated groups (Fisher exact test: Group A, p = 0.03; Group B, p = 0.002). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (chi2 = 6.13, p = 0.01).
The direction in which the fundus projects was chosen as the morphological criterion between endovascular and surgical methods. The authors propose that microsurgical clip application should be the preferred option in the treatment of ACoA aneurysms with anteriorly directed fundi and that endovascular packing be selected for those lesions with posteriorly directed fundi, depending on morphological criteria 23).
Cohen et al., describe a technique for T-configured stent-assisted coiling in the management of ruptured wide-necked AcomA aneurysms by means of two simultaneous microsystems that allowed placement of two nitinol self-expandable Leo+ Baby stents (Balt Therapeutics, Montmorency, France) followed by coiling. Technical details and comparison to other dual stent configurations were presented and briefly discussed 24).
A 69-year-old male without a past history of mental disorders and neurological symptoms presented with a 2-month history of anxiety, sadness, lack of pleasure in usual activities, fatigue, difficulties falling asleep and waking up early in the morning, reduced appetite, and weight loss. The patient was diagnosed with major depressive disorder and antidepressant treatment was initiated. Subsequent non-contrast computed tomography (CT) of the head demonstrated hypointense oval-shaped lesion within the projection of the anterior communicating artery. CT angiography confirmed the diagnosis of a 0.8 × 0.6 cm saccular aneurysm originating from the anterior communicating artery and anterior cerebral artery. The patient underwent microsurgical clipping of the aneurysm. On psychiatric assessment 1 month after the surgery, there were no signs of depressive disorder and antidepressive treatment was discontinued. On follow-up visit 1 year after the surgery, the patient did not have any mood symptoms.
The case indicates that organic brain lesions, including intracranial aneurysms, should be suspected in elderly patients presenting with their first episode of mental disorder 25).
Seung et al., present an unusual case of bitemporal hemianopsia caused by a large intracranial aneurysm of the ACoA. A 41-year-old woman was admitted to our neurosurgical department with a sudden-onset bursting headache and visual impairment. On admission, her vision was decreased to finger counting at 30 cm in the left eye and 50 cm in the right eye, and a severe bitemporal hemianopsia was demonstrated on visual field testing. A brain computed tomography scan revealed a subarachnoid hemorrhage at the basal cistern, and conventional cerebral catheter angiography of the left internal carotid artery demonstrated an 18×8 mm dumbbell-shaped aneurysm at the ACoA. Microscopic aneurysmal clipping was performed. An ACoA aneurysm can produce visual field defects by compressing the optic chiasm or nerves. We emphasize that it is important to diagnose an aneurysm through cerebrovascular study to prevent confusing it with pituitary apoplexy 26).
A 55-year-old man presented with a 3-year history of visual impairment associated with personality changes. His sister had died after an intracerebral aneurysmal rupture. An examination revealed poor visual acuity in the right eye with a field defect, as well as impaired neurocognition. Computed tomographic (CT) angiography (Panel A) and magnetic resonance imaging of the brain revealed a partially thrombosed, calcified, 7-cm aneurysm of the anterior communicating artery, with surrounding edema (Panel B). Thrombectomy and aneurysmal repair were performed to reduce the risk of aneurysmal rupture and to alleviate the mass effect. The patient recovered from surgery and had improvement in his neurocognitive deficits and vision, and he was able to return to work. His condition remained stable 2 years later, and delayed CT showed collapse of the aneurysmal sac (Panel C). Giant aneurysms (>2.5 cm) represent a small proportion of brain aneurysms but are associated with a high rupture rate when left untreated. Approximately 20% of patients with a brain aneurysm have a first-degree relative with a brain aneurysm 27).
A study reports the case of a 42-year-old man who suffered a ruptured aneurysm of the anterior communicating artery. His memory capabilities were assessed after a considerable recovery period during which many of his memory deficits ameliorated. His scan revealed a left frontal lesion and many of his deficits were characteristic of frontal impairment. He was impaired on temporal discrimination, and he showed marked source forgetting. He also performed badly on the Brown-Peterson task, and we suggest that this is another task that may be characteristic of frontal impairment. In contrast, the patient showed normal or near normal performance on some memory tasks but not on others. It is concluded that the patient’s frontal signs are similar to those found in Korsakoff’s Syndrome, but that his memory impairment is qualitatively different from that encountered in patients with the amnesic syndrome 28).