Anterior Communicating Artery Aneurysms: An Overview

Abstract

AComA aneurysms are most commonly found at the A1-A2 junction on the dominant side. The angle of the arteries at the bifurcation and the direction of blood flow are factors of hemodynamic stress in the apical region where these aneurysms often develop. They exist at the bifurcation of dominant A1, A2 and AComA and usually point in the direction away from the dominant A1. They are more prone to rupture and demonstrate the highest incidence of post-operative morbidity among anterior circulation aneurysms. Consideration of aneurysm morphology may be used to guide approaches in AComA aneurysms. Resection of the gyrus rectus in combination with a pterional approach was popularized by Yasargil and it became the standard for treatment or exposure of AComA aneurysms, although other skull base approaches are also widely used. Clip selection is of extreme importance and the preservation of blood flow to the perforators should be emphasized. Adequate dissection and exposure of the entire “H” complex prior to clipping is the key to a successful outcome. Separating the perforators from the neck or dome of the artery and preserving the parent vessel presents a substantial challenge to the surgeon when the aneurysm is behind the parent artery, making it difficult to achieve a good outcome.

AComA aneurysms - approach to aneurysm - clipping techniques

References

• 1 Kassell NF, Torner JC, Haley Jr Ec, 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
• 2 Locksley HB. Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage: section V.  J Neurosurg. 1966;  25 219-239
• 3 Andaluz N, Loveren H van, Keller J, Zuccarello M. Anatomic and clinical study of the orbitopterional approach to anterior communicating artery aneurysms.  Neurosurg. 2003;  52 1140-1149
• 4 Yasargil MG. Microsurgery applied to neurosurgery. Thieme, Stuttgart, Academic Press, New York 1969: 126-130
• 5 Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms.  Surg neurol. 1975;  3 7-14
• 6 Yasargil MG. Anterior cerebral and anterior communicating artery aneurysms. In: Yasargil MG, ed. Microneurosurgery, vol II. Clinical considerations, surgery of the intracranial aneurysms and results. Stratton: George Thieme Verlag, New York 1984: 165-231
• 7 Kasuya H, Shimizu T, Nakaya K, Sasahara A, Hori T, Takakura K. Angles between A1 and A2 segments of the anterior communicating artery visualized by three-dimentional computed tomographic angiography and association of anterior communicating artery aneurysms.  Neurosurgery. 1999;  45 89-96
• 8 Stehbens WE. Etiology of intracranial berry aneurysms.  J Neurosurg. 1989;  70 823-831
• 9 Ferguson GG. Physical factors in the initiation, growth, and rupture of human intracranial saccular aneurysms.  J Neurosurg. 1972;  37 666-677
• 10 Yasargil MG. Microsurgical anatomy of the anterior cerebral-anterior communicating artery complex. In: Yasargil MG., ed. Microneurosurgery, vol I. Microsurgical anatomy of the basal cisterns and vessels of the brain. Stratton: George Thieme Verlag, New York 1984: 1-32
• 11 Yasargil MG, Fox JL, Ray MW. The operative approach to aneurysms of the anterior communicating artery.  In: Krayenbuhl et al., eds. Advances and technical standards in neurosurgery, vol 2. Springer, Wien, New York 1975: 113-170
• 12 Baptista AG. Studies on the arteries of the brain. II. The anterior cerebral artery: some anatomic features and their clinical implications.  Neurology. 1963;  13 825-835
• 13 Uchino A, Nomiyama K, Takase Y, Kudo S. Anterior cerebral artery variations detected by MR angiography.  Neuroradiology. 2006;  48 647-652
• 14 Wanibuchi M, Kurokawa Y, Ishiguro M, Fujishige M, Inaba K. Characteristics of aneurysms arising from the horizontal portion of the anterior communicating artery.  Surg Neurol. 2001;  55 148-155
• 15 Ito J, Washiyama K, Kim CH, Ibuchi Y. Fenestration of the anterior cerebral artery.  Neuroradiology. 1981;  21 277-280
• 16 Sanders WP, Sorek PA, Mehta BA. Fenestration of intracranial arteries with special attention to associated aneurysms and other anomalies.  AJNR Am J Neuroradiol. 1993;  14 675-680
• 17 Taylor R, Connolly Jr ES, Duong H. Radiographic evidence and surgical confirmation of a saccular aneurysm on a hypoplastic duplicated A1 segment of the anterior cerebral artery.  Case report. Neurosurgery. 2000;  46 482-484
• 18 Inagawa T. Dissection from fundus to neck for ruptured anterior and middle cerebral artery aneurysms at the acute surgery.  Acta Neurochir (Wien). 1999;  141 563-570
• 19 Sadatomo T, Yuki K, Migita K, Taniguchi E, Konama Y, Kurisu K. The characteristics of the anterior communicating artery aneurysm complex by three-dimensional digital subtraction angiography.  Neurosurg Rev. 2006;  29 201-207
• 20 Birknes J, Hwang S, Pandey A, Cockroft K, Dyer A, Benitez R, Veznedaroglu E, Rossenwasser R. Feasibility and limitations of endovascular coil embolization of anterior communicating artery aneurysms: Morphological considerations.  Neurosurgery. 2006;  59 43-52
• 21 Sano H. Anterior communicating artery aneurysms. In: Sekhar L, Fessler R, eds. Atlas of neurosurgical techniques: Brain. Stuttgart, Thieme, New York 2006: 142-151
• 22 Hino A, Fujimoto M, Iwamoto Y, Oka H, Echigo T. Surgery of proximal anterior cerebral artery aneurysms.  Acta Neurochir (Wien). 2002;  144 1291-1296
• 23 Kempe LG, VanderArk GD. Anterior communicating artery aneurysms: Gyrus rectus approach.  Neurochirurgia (Stuttg). 1971;  14 63-70
• 24 Al-Mefty O, Anand VK. Zygomatic approach to skull base lesions.  J Neurosurg. 1990;  73 668-673
• 25 Sekhar LN, Kaila KK, Yonas H, Wright DC, Ching H. Cranial base approaches to intracranial aneurysms in the subarachnoid space.  Neurosurgery. 1994;  35 472-483
• 26 Uttey D, Archer DJ, Marsh HT, Bell BA. Improved access to lesions of the central skull base by mobilization of the zygoma: experience with 54 cases.  Oper Tech Neurosurg. 1998;  28 99-104
• 27 Gonzalez L, Crawford N, Horgan M, Deshmukh P, Zabramski J, Spetzler R. Working area and angel of attack in three cranial base approaches: Pterional, orbitozygomatic and maxillary extension of the orbitozygomatic approach.  Neurosurgery. 2002;  50 550-557
• 28 Tanriover N, Ulm A, Rhoton A, Kawashima M, Yoshida N, Lewis S. One-piece versus two-piece orbitozygomatic crainiotomy: Quantitative and qualitative considerations.  Neurosurgery. 2006;  58 229-237
• 29 Figueiredo E, Deshmukh P, Zabramski J, Preul M, Crawford N, Siwanuwatn R, Spetzler R. Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex.  Neurosurgery. 2005;  56 397-405
• 30 Lougheed W. Selection, timing and technique of aneurysm surgery of the anterior circle of Willis.  Clin Neurosurg. 1969;  16 95-113
• 31 Ito Z. The microsurgical approach anterior interhemispheric approach suitably applied to ruptured aneurysms of the anterior communicating artery in acute stage.  Acta Neurochir (Wien). 1982;  63 85-99
• 32 El-Noamany H, Nakagawa F, Hongo K, Kakizawa Y, Kobayashi S. Low anterior interhemispheric approach - A narrow corridor to aneurysms of the anterior communicating artery.  Acta Neurochir (Wien). 2001;  143 885-891

Correspondence