Endovascular treatment of tiny ruptured anterior communicating artery aneurysms

Abstract

Introduction: Because of its high complication rate, the endovascular treatment (EVT) of anterior communicating artery (ACoA) aneurysms less than 3 mm in maximum diameter remains controversial. We evaluated EVT of tiny ruptured ACoA aneurysms with Guglielmi detachable coils (GDCs).

Methods: We treated 19 ruptured ACoA aneurysms with a maximum diameter of <or=3 mm with GDCs. The pretreatment Hunt and Hess score was grade 1 in four patients, grade 2 in six, grade 3 in six, and grade 4 in three. The patients were clinically assessed before and after treatment and with multiple angiographic follow-up studies.

Results: All EVTs were successful; there were no aneurysm perforations or any other treatment-related complications. In five patients older than 80 years the transfemoral approach was difficult, and the direct carotid approach was used. Complete and near-complete occlusion was achieved in 16 patients (84.2%) and 3 patients (15.8%), respectively. Of the 19 patients, 16 (84.2%) were followed angiographically for a median of 38.5 months (range 16-72 months). None demonstrated recanalization of the aneurysm requiring additional treatment. In 15 patients (78.9%) the final outcome was good (modified Rankin scale, mRS, score 0-2), and 3 patients (15.8%) died or suffered severe disability (mRS score 4-6). None of 18 patients who were followed clinically for a median of 39.5 months (range 17-84 months) experienced rebleeding.

Conclusion: Even tiny ruptured ACoA aneurysms can be safely treated by EVT by expert neurointerventionalists using advanced techniques.

Fig. 1

Patient 4. a Angiogram of the left ICA shows a tiny ACoA aneurysm with a maximum diameter of 2.5 mm (arrow). b Photograph of a steam-shaped microcatheter. The shaping mandrel is bent to conform to the shape of the horizontal portion of the anterior cerebral artery. c Unsubtracted image of the skull obtained with the road-mapping technique during treatment. Embolization was with a GDC-10 Soft coil measuring 2×60 mm. d Angiogram of the left ICA obtained at the end of the procedure shows complete occlusion of the aneurysm. The diameter of the coil mass was larger than that of the aneurysm sac before embolization, indicating aneurysm distention

Fig. 2

Patient 5. a Angiogram of the left ICA shows a tiny ACoA aneurysm with a maximum diameter of 2.5 mm. b Unsubtracted image of the skull obtained with the road-mapping technique during treatment. Embolization was with a GDC-10 Soft coil measuring 2×60 mm. c Angiogram of the left ICA obtained at the end of the procedure shows complete occlusion of the aneurysm. d Angiogram of the left ICA obtained at the 3-month follow-up shows minor recanalization of the neck (arrow). e The minor neck filling was stable at the 48-month follow-up

Fig. 3

Patient 8. a Angiogram of the left ICA shows a tiny ACoA aneurysm with blebs. b Angiogram of the left ICA obtained at the end of the procedure. The aneurysm sac and blebs are completely occluded with coils. The coil mass is larger than the aneurysm sac before embolization (indicating aneurysm distention)