Clinical Outcomes of Coil Embolization for Ruptured Anterior Communicating Artery Aneurysms with a “Coil First” Policy

Abstract

Background and purpose: Endovascular coil embolization is an acceptable first-line treatment modality for ruptured anterior communicating artery (AcoA) aneurysms. The management varies among institutions because the causes for selection of coil embolization include not only aneurysm morphology but also institutional factors. We assess our experience with a "coil first" policy and determine predictors of complications. In addition, we report our institutional factors. Materials and methods: We retrospectively analyzed 27 consecutive patients with a ruptured AcoA aneurysm who underwent coil embolization at our institution between August 2013 and July 2016. During this period, none of the patients had a crossover to clipping. More than half of the neurosurgeons at our institution had much more experience with coils than with clips.Results: Of the patients, 11 were women (40.7%). The mean age of the patients was 58.0 years. The overall clinical outcome was modified Rankin scale (mRS) score of 0-2 in 16 patients (59.3%), 3 or 4 in 4 (14.8%), and 5 or 6 in 7 (25.9%). Intraprocedural rupture (IPR) occurred in 4 patients whose aspect ratios (ARs) were <1.5. Of the 4 patients, 1 had a small basal outpouching (SBO) associated with IPR.Delayed rebleeding occurred 3 years after the initial coil embolization. Three patients underwent additional treatment without procedure-related complications. One of the recurrent aneurysms with a SBO was treated with clipping in the chronic stage.Conclusion: As worse outcomes are associated with IPR and delayed rebleeding, crossover to clipping in the case of AR of <1.5 or SBO may allow a safer obliteration in the acute stage. Intentional partial coil embolization followed with additional clipping in the chronic stage, however, may improve procedural safety.