[Ruptured anterior communicating artery aneurysm. Therapeutic options in 119 consecutive cases].

Anevrismes rompus de l'artère communicante antérieure. Choix thérapeutique à propos d'une série consécutive de 119 cas.

Publisher: Masson Country of Publication: France NLM ID: 0401057 Publication Model: Print Cited Medium: Print ISSN: 0028-3770 (Print) Linking ISSN: 00283770 NLM ISO Abbreviation: Neurochirurgie Subsets: MEDLINE

Original Publication: Paris : Masson

Cerebral Revascularization* ; Embolization, Therapeutic*; Aneurysm, Ruptured/*surgery ; Cerebral Arteries/*surgery ; Intracranial Aneurysm/*surgery; Adolescent ; Adult ; Aged ; Aneurysm, Ruptured/mortality ; Aneurysm, Ruptured/pathology ; Cerebral Angiography ; Cerebral Arteries/pathology ; Disability Evaluation ; Female ; Humans ; Intracranial Aneurysm/mortality ; Intracranial Aneurysm/pathology ; Male ; Middle Aged ; Prospective Studies ; Tomography, X-Ray Computed ; Treatment Failure ; Treatment Outcome

Background and Purpose: The respective roles of endovascular and surgical treatment must be clearly defined in the management of ruptured anterior communicating artery (AcoA) aneurysm. The aim of our study was to report our results, using the aneurysm direction as the main morphological argument to choose between microsurgery and endovascular embolization. Morbidity and mortality, causes of unfavorable outcome and morphological results were also assessed.
Patients and Methods: Our prospective study included 119 patients: 89 treated by microsurgery and 30 undergoing embolization with Guglielmi Detachable Coils (GDC). When the aneurysm had an anterior direction (fundus of the aneurysm in front of the pericallosal arteries), we attempted microsurgery. If the fundus of the aneurysm was behind the pericallosal arteries, we selected the most adapted procedure after discussion with the neurovascular team, taking into account the physiological status, treatment risk and neck size. Preoperative status of the patients was assessed according to the Hunt and Hess (HH) classification. Cerebral CT-scan and angiograms were routinely performed after treatment to determine causes of unfavorable outcome (GOS>1) and the morphological results.
Result: Overall clinical outcome was excellent (GOS1) for 63.0% of patients, good (GOS2) for 10.1%, fair (GOS3) for 13.4%, poor (GOS4) for 2.5%. The mortality rate was 10.9%. Among the 82 patients in good preoperative grade (HHIII), 8 (21.6%) achieved an excellent outcome. However permanent morbidity or death occurred in 15 patients (78.4%). Permanent disability and death were related to initial subarachnoid hemorrhage and were observed 21.3% of patients in the microsurgical group and 30.0% in the endovascular group [Fisher's Exact Test; p=0.33]. Procedure-related permanent disability and death rates were 9.0% for the microsurgical group and 23.3% for the endovascular group (p=0.06) respectively. In the microsurgical group, the only morphologic characteristic which significantly correlated with the occurrence of vessel occlusion was the fundus direction (p=0.03). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (p=0.04).
Conclusion: In our experience, the direction of the aneurysm was the main morphological criterion in choosing between microsurgery or endovascular procedure for the treatment of AcoA aneurysm. We propose that microsurgical clipping should be preferred for AcoA aneurysms with anterior direction, and depending on morphological criteria, endovascular packing for those with posterior direction.

Date Created: 20040421 Date Completed: 20040525 Latest Revision: 20200423

20231215

10.1016/s0028-3770(04)98302-6

15097917