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 Table of Contents  
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 98-102

Outcome of microsurgical clipping of anterior communicating aneurysms: A single-centre experience

Department of Neurosurgery, Velammal Medical College Hospital, Madurai, Tamil Nadu, India

Date of Submission23-Jan-2022
Date of Decision29-Jan-2022
Date of Acceptance02-Feb-2022
Date of Web Publication5-Apr-2022

Correspondence Address:
Dr. M Ganesh Kumar
Department of Neurosurgery, Velammal Medical College Hospital, Madurai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcvs.jcvs_10_22

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Anterior communicating (ACOM) aneurysms are the most common intracranial aneurysms. About 30%–40% of ruptured intracranial aneurysms are ACOM aneurysms. Its complex structural and anatomical variability and its critical location pose a great challenge to the surgeon during microsurgical clipping. We share our experience in clipping these aneurysms and its outcome. The aim was to study the outcome following microsurgical clipping of ACOM artery aneurysm presenting with rupture and subarachnoid haemorrhage and to determine the factors which dictate the clinical outcome after 6 months. The study includes all cases of ruptured ACOM aneurysms who underwent microsurgical clipping between the period of 2016 and 2020. The medical records were analysed retrospectively and results were recorded. The study shows that the outcome of the patients depends on presenting World Federation of Neurological Surgeons grade, anterosuperiorly projecting aneurysms are at high risk for intraoperative rupture and complications such as lacunar infarcts are common with the usage of temporary clips.

Keywords: Anterior communicating aneurysm, Fisher grading, Glascow Outcome Score, projection of fundus, World Federation of Neurological Surgeons grading

How to cite this article:
Kumar M G, Prasad R, Kumar S, Pravallika A. Outcome of microsurgical clipping of anterior communicating aneurysms: A single-centre experience. J Cerebrovasc Sci 2021;9:98-102

How to cite this URL:
Kumar M G, Prasad R, Kumar S, Pravallika A. Outcome of microsurgical clipping of anterior communicating aneurysms: A single-centre experience. J Cerebrovasc Sci [serial online] 2021 [cited 2022 May 22];9:98-102. Available from: http://www.jcvs.com/text.asp?2021/9/2/98/342554

  Introduction Top

Among all the intracranial aneurysms, a ruptured anterior communicating (ACOM) aneurysm is the most frequent one. Even though endovascular techniques are evolving at a rapid rate, microsurgical clipping remains the gold standard surgical protocol. Vowing to their complex anatomical variations and multiple perforators, understanding and pre-operative anatomical evaluation of these ACOM aneurysms plays a crucial role in outcomes. Our study aims at analysing the various factors affecting the clinical outcome and complications associated with it, both intraoperative and post-operative period.

  Materials And Methods Top

This is a retrospective cohort study which includes all the patients presenting with ruptured ACOM aneurysms between 2016 and 2020. All the demographic details are tabulated carefully. The World Federation of Neurological Surgeons (WFNS) scoring and Fischer grading is recorded in all the cases and intra and post-operative complications are noted down. Patients are being followed regularly and Glasgow Outcome Scale (GOS) is recorded at 1, 3 and 6 months to determine the outcome.

  Results Top

We conducted a retrospective cohort study where all patients with ACOM aneurysms who are treated by microsurgical clipping are included and their pre-operative, intraoperative and post-operative records are analysed. All the patients are closely followed and the condition in terms of GOS is documented. Among thirty patients, males were 12 and females were 18 with a ratio of 2:3.

The age of patients ranged from 25 years to 75 years. The mean age of the study group is 51.63 [Table 1] and [Graph 1].
Table 1: Age distribution of study group

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On admission, WFNS grading is used for clinical grading in all patients. Majority of them were in Grade 3 and Grade 4 with ten cases in each grading [Table 2] and [Graph 2].
Table 2: Distribution of patients based on their World Federation of Neurosurgical Societies grading

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Initial computed tomography (CT) was done in all the patients and Fischer grading was done. Most of the patients were in Grade 3 [Table 3] and [Graph 3].
Table 3: Distribution of patients based on their Fisher's grading

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All the patients were subjected to CT angiogram to study the anatomy, neck size, fundus position and direction of aneurysm and the following observations were made [Table 4] and [Graph 4].
Table 4: Distribution of patients based on their aneurysm neck size

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Direction of fundus and its related anatomy is a crucial factor for successful aneurysm clipping. In our study, fundus projection appears to be equally distributed in all directions [Table 5] and [Graph 5]. Intraoperative rupture of the aneurysm while dissecting the neck is one of the common hurdles faced by surgeons. Direction of the fundus is an important factor among many factors for rupture. We experienced the highest number of intraoperative ruptures in aneurysms which were pointing anterosuperiorly (five cases) because of difficulty in exposing the neck, leading to rupture [Table 6] and [Graph 6].
Table 5: Direction of fundus projection

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Table 6: Correlation between aneurysm projection and intraoperative rupture

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  Complications Top

Various post complications noted in post-operative period are tabulated in [Table 7]. Vasospasm was noted in four patients post-operatively, which was successfully managed in intensive care unit. Lacunar infarcts and other major infarcts were observed and are attributed to the usage of temporary clips. Cerebrospinal fluid (CSF) leak and anosmia are noted in patients undergoing interhemispheric approach. Hydrocephalus is noted in five patients who resolved spontaneously in three patients and two patients had to undergo CSF diversion procedures.
Table 7: Post-operative complication following microsurgical clipping of anterior communicating artery aneurysms

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  Discussion Top

ACOM aneurysms are the most common intracranial aneurysms accounting for up to 30% of all intracranial aneurysms and account for the most common ruptured aneurysms.[1],[2],[3] According to recent studies, ACOM aneurysms have a high risk of rupture irrespective of their size, and hence, active intervention is indicated even in small aneurysms.[4],[5] Among the thirty patients with ACOM aneurysms in our study, a high prevalence (33.3%) of ACOM aneurysms existed in the age range of 50–60 years. In a large series conducted by Zhang et al., a high prevalence of ACOM aneurysm was noted between 50 and 70 years.[6] The worldwide prevalence of cerebral aneurysms is estimated at 3.2%, with an overall gender ratio of 1:1 at the mean age of 50 years. After the age of 50 years, a female predominance of 2:1 is seen.[7] Our study also corresponds to international literature of female preponderance in the incidence of ACOM aneurysms with a female-to-male ratio of 3:2.

Cerebral vasospasm is the major cause of delayed ischaemia in patients with subarachnoid haemorrhage (SAH). The Fisher grading scale has been used to predict patients at risk of developing vasospasm. About 70% of the patients develop vasospasm radiologically and clinical vasospasm is seen in 30%–40% of the patients.[8],[9] The Fisher grading scale, first described in 1980, has been used to predict which SAH patients that are at risk of developing vasospasm. The grading scale developed by Fisher et al.[10] described the amount and distribution of subarachnoid blood seen on an initial CT. However, in our study, we could not establish any strong relationship between the incidence of vasospasm and Fisher grading, as suggested by many previous studies.

Multiple studies in the past with respect to predictors of outcome after aneurysmal SAH proved that WFNS grading at presentation is one of the most reliable prognosticating factors, and this held true in our study. The International Cooperative Study on the Timing of Aneurysm Surgery by Kassell et al. observed that WFNS grade had a direct correlation with the outcome of a SAH.[11] Chiang et al., on studying 56 consecutive patients for prediction of outcome in a SAH, found the patient's worst clinical grade to be most predictive of the outcome, especially when the patient is assessed using the WFNS scale or the Glasgow Coma Scale.[12]

The results of our study are also correlating with the available literature in terms of WFNS grading-dependent outcome measured by GOS at 6-month follow-up [Table 8] and [Graph 7].
Table 8: Correlation between World Federation of Neurosurgical Societies grading and Glasgow Outcome Scale assessed at 6-month follow-up

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Intra-operative rupture (IOR) of aneurysms, is the least desired and potentially lethal complication of neurosurgical treatment. Meticulous microdissection techniques, detailed planning of surgical stages and predicting possible incidents can lead to the reduction of mortality and morbidity. Intraoperative rupture of cerebral aneurysms is scarcely mentioned in literature.

The risk factors for intraoperative rupture are being studied extensively such asgender, age, day of surgery and direction of fundus, but none has been proven. The relationship between the localisation of aneurysm and the occurrence of IOR is not clearly defined. Sundt et al.[13] did not find a correlation between the location of aneurysm and IOR. For some aneurysms with special directions (superiorly projecting aneurysms), the anteroposterior relationship of bilateral A2 could affect the exposure of the aneurysm neck, the difficulty of operation, the resection rate of the gyrus rectus and the post-operative complications. Therefore, more research is needed to confirm the corresponding side selection, providing a very valuable idea for us to more elaborately study surgical strategies for ACOM aneurysm treatment.[14]

However, in a large series by Nahed et al. it was found that anteriorly projecting aneurysms often block the contralateral A1, making it more difficult in delineating the neck; therefore, the surgeon approaches the vessels in a clockwise fashion as follows: (1) the ipsilateral A1 is followed to the ipsilateral A2, (2) the contralateral A2 is identified and (3) the contralateral A1 segment is dissected last because this manipulation is associated with the highest risk of aneurysmal rupture. In contrast, posteriorly projecting aneurysms do not obstruct exposure, allowing both A1 segments to be dissected first and the deeper A2 segments last.[15] Our study correlates with this study as well with the highest number of ruptures in anterosuperiorly directing aneurysms opposite to the direction of dominant A1.

Post-operative complications such as infarct and hydrocephalus are more common with people presenting with WFNS Grade 4 and Grade 5, which is again proved in our study and emphasises the importance of patients clinical status at presentation affects the outcome.[16]

Finally, our study does not establish any relationship between IOR and the size of aneurysm or day of surgery.

  Conclusion Top

Highest ACOM aneurysm prevalence noted in 50–60 age groups with female preponderance. Fischer grading does not correlate with pre-operative vasospasm. Projection of aneurysm ice anterosuperiorly directing fundus opposite to dominant A1 is one of the significant risk factors for intraoperative rupture due to its complicated anatomy during dissection. WFNS grading is a reliable scale for predicting the outcome after surgery. Usage of temporary clips increases the risk of lacunar infarcts or massive infarcts along parent vessels.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Froelich S, Cebula H, Debry C, Boyer P. Anterior communicating artery aneurysm clipped via an endoscopic endonasal approach: Technical note. Neurosurgery 2011;68:310-6.  Back to cited text no. 1
Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med 2012;366:2474-82.  Back to cited text no. 2
Wong H, Banfield J, Hughes N, Shankar JJ. Are anterior communicating aneurysms truly anterior communicating aneurysms? An observational study. World Neurosurg 2019;125:E1089-92.  Back to cited text no. 3
Bijlenga P, Ebeling C, Jaegersberg M, Summers P, Rogers A, Waterworth A, et al. Risk of rupture of small anterior communicating artery aneurysms is similar to posterior circulation aneurysms. Stroke 2013;44:3018-26.  Back to cited text no. 4
Lee GJ, Eom KS, Lee C, Kim DW, Kang SD. Rupture of very small intracranial aneurysms: Incidence and clinical characteristics. J Cerebrovasc Endovasc Neurosurg 2015;17:217-22.  Back to cited text no. 5
Zhang XJ, Gao BL, Hao WL, Wu SS, Zhang DH. Presence of anterior communicating artery aneurysm is associated with age, bifurcation angle, and vessel diameter. Stroke 2018;49:341-7.  Back to cited text no. 6
Jersey AM, Foster DM. Cerebral aneurysms. In: A Service of the National Library of Medicine, National Institute of Health (NCBI Bookshelf). Treasure Island: Stat Pearls; 2019.  Back to cited text no. 7
Kassell NF, Sasaki T, Colohan AR, Nazar G. Cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Stroke 1985;16:562-72.  Back to cited text no. 8
Weir B, Macdonald RL, Stoodley M. Etiology of cerebral vasospasm. Acta Neurochir Suppl 1999;72:27-46.  Back to cited text no. 9
Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980;6:1-9.  Back to cited text no. 10
Kassell NF, Torner JC, Haley EC Jr., Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 1990;73:18-36.  Back to cited text no. 11
Chiang VL, Claus EB, Awad IA. Toward more rational prediction of outcome in patients with high-grade subarachnoid hemorrhage. Neurosurgery 2000;46:28-35.  Back to cited text no. 12
Sundt TM Jr., Kobayashi S, Fode NC, Whisnant JP. Results and complications of surgical management of 809 intracranial aneurysms in 722 cases. Related and unrelated to grade of patient, type of aneurysm, and timing of surgery. J Neurosurg 1982;56:753-65.  Back to cited text no. 13
Chen J, Li M, Zhu X, Chen Y, Zhang C, Shi W, et al. Anterior communicating artery aneurysms: Anatomical considerations and microsurgical strategies. Front Neurol 2020;11:1020.  Back to cited text no. 14
Nahed BV, Ogilvy CS. Anterior Circulation Aneurysms. In Stroke WB Saunders. 2011. p. 1301-21.   Back to cited text no. 15
Zhao B, Cao Y, Tan X, Zhao Y, Wu J, Zhong M, et al. Complications and outcomes after early surgical treatment for poor-grade ruptured intracranial aneurysms: A multicenter retrospective cohort. Int J Surg 2015;23:57-61.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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