Endovascular Management of Distal Anterior Cerebral Artery Aneurysms: A Multicenter Retrospective Review

Factors Affecting the Outcome after Surgical Clipping of Ruptured Distal Anterior Cerebral Artery (DACA) Aneurysms

Objective  The purpose of this study is to assess demographic, clinical, and unique morphological characteristics of distal anterior cerebral artery (DACA) aneurysm. The relation of outcome included Glasgow Outcome Scale (GOS) using various independent variables, Hunt and Hess clinical grade (H&H), Miller Fischer grade, intraoperative rupture, and comparison of outcomes at discharge and last follow-up. Methods  Demographic data, aneurysm characteristics, and treatment outcomes were evaluated in 28 ruptured DACA aneurysms operated over a period of 13 years. Association between independent variables and dependent variables (GOS) at discharge and at last follow-up (13 years) was analyzed, and the interrelationship between these factors and outcome was evaluated. GOS was used to assess functional outcomes. Results  Over a period of 13 years, 500 patients harboring ruptured intracranial aneurysms were surgically clipped, and out of them 28 patients (5.6%) had ruptured DACA aneurysms. In this series, 20 (71.4%) patients had low grade and 8 (28.6%) had high grade H&H. Out of the 28 patients, 19 (67.8%) had good recovery, 6 (21.5%) were severely disabled, and 3 (10.7%) died at the time of discharge. On the last follow-up (13 years), smoking ( p -value 0.03) and use of temporary clip ( p -value 0.00) were significant predictors for unfavorable outcome. Conclusion  The results of our case series show that even with ruptured aneurysm excellent overall outcome after microsurgical clipping can be achieved, even though among cerebral aneurysms, DACA aneurysm is considered to have less favorable outcome. Alcohol consumption and use of temporary clip were the predictors for unfavorable outcome at the time of discharge. On the last follow-up, smoking and use of temporary clip were found to be the risk factors for unfavorable outcome. Although the small sample size of this study is a limitation, smoking and use of temporary clip play an important role on the overall outcome. The aim of this study was to analyze data to determine factors which may influence outcome after surgical clipping of ruptured DACA aneurysms.

Mini anterior interhemispheric approach for A3 segment distal anterior cerebral artery aneurysms

INTRODUCTION

Aneurysms of the A3 segment of the distal anterior cerebral artery (DACA), in relation to the genu of the corpus callosum, are specific sub-group which pose unique surgical challenges due to their discrete anatomical location. We describe a mini-anterior interhemispheric approach which can be safely utilised to clip these aneurysms rather than the traditional bifrontal approach.

METHODS

Retrospective analysis of the clinical and radiological data of ruptured DACA-A3 aneurysms operated between 2014 and 2021 at our institute. A curvilinear scalp incision within the hairline followed by raising small, unilateral, free frontal bone flap, avoiding the opening of frontal sinus. Superior sagittal sinus is displaced medially, inter-hemispheric dissection carried out with posterior trajectory and small callosotomy is performed. DACA is skeletonised, proximal control is established, and the A3 aneurysm is dissected and clipped.

RESULT

Our cohort of 18 patients had a definite female preponderance (F:M::2:1) with mean age of 55.6 years. On admission three patients were categorized as WFNS Grade I, thirteen in Grade II, and two in Grade III for subarachnoid haemorrhage. All the patients had evidence of blood in the interhemispheric fissure; intraparenchymal haemorrhage was seen in seven, with intraventricular haemorrhage in six patients. Within the A3 segment six aneurysms were infragenu (inferior), eight were at the genu (anterior) and four were supragenu (superior). Two (11.1%) elderly patients succumbed post-surgery following ischemic infarcts and associated complications. At the time of follow-up at 3 months of the remaining sixteen (72.2%) patients, thirteen had a good outcome (mRS 0-3) and three (16.7%) had a poor outcome (mRS > 3).

CONCLUSION

The mini anterior interhemispheric is an effective minimally invasive alternative for A3 segments aneurysms and helps to avoid the complications of the conventional bifrontal interhemispheric approach.