Contemporary Management of Distal Anterior Cerebral Artery Aneurysms: A Dual-Trained Neurosurgeon's Perspective

Furtado, Sunil V.; Jayakumar, Dravya; Perikal, Parichay J.; Mohan, Dilip

doi:10.1055/s-0041-1735823

Cited by 11 publications

(16 citation statements)

References 22 publications

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“…2,9 There are many known factors which affect the outcome of DACA aneurysms after surgical intervention, but there is sparsity of publication on these issues. 1,2,4,9,16,25 High H&H and MF grades, ICH, IVH, hydrocephalus, IOR, timing of surgery, and advanced age have been attributed for poor outcome after intervention. 1,9,10,25 Furtado et al found poor clinical grade on admission and initial ICH as a risk factor for poor prognosis.…”

Section: Discussionmentioning

confidence: 99%

“…The incidence is estimated to be approximately 1 to 9% of all intracranial aneurysms. [1][2][3][4][5][6] DACA aneurysms are unique in terms of their incidence, clinical presentation, location, morphology, and treatment outcome. 7,8 There are two modalities of treatment of ruptured DACA aneurysm and they are surgical clipping or endovascular procedure and occasionally combination of both.…”

Section: Introductionmentioning

confidence: 99%

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

Sharma,

Karki,

Joshi

et al. 2023

Asian J Neurosurg

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Sharma,

Karki,

Joshi

et al. 2023

Asian J Neurosurg

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“…Poor prognosis following intervention has been ascribed to high preoperative clinical grades, ICH, IVH, hydrocephalus, intraoperative rupture of aneurysm, scheduling of surgery, and old age. [3,5,10,16] On multivariate analysis, we found two variables with signi cant impacts on the long-term outcomes: temporary clipping and a poor grade at admission (WFNS grade > 2). Presentation with poor clinical grade is a known factor and remains largely an unmodi able variable.…”

Section: Functional Outcomes and Perspectivesmentioning

confidence: 98%

“…While endovascular treatment has been found to be favorable in infra-callosal aneurysms, those with complex con guration have better results with surgery. [1,5] In addition, aneurysm location on the DACA have traditionally dictated the surgical approach as well. [8] However, the clinical, operative and outcome comparison between proximal and distal DACA aneurysms are seldom reported.…”

mentioning

confidence: 99%

Under recognized yet a clinically relevant impact of aneurysm location in Distal Anterior Cerebral Artery (DACA) aneurysms: insights from a contemporary surgical experience

Haldar,

Das,

Kanjilal

et al. 2024

Preprint

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Background Aneurysms of the distal anterior cerebral artery (DACA) are rare but challenging. Even though it is known that aneurysm location on the DACA territory has treatment considerations, the literature is unclear about its clinical and prognostic role. Material and methods Our surgical experience over the last 5 years were reviewed to compare the clinical, operative, and outcome characteristics between aneurysms located below the mid portion of the genu of the corpus callosum (called proximal aneurysms) to those distal to this point (called distal aneurysms). A prognostic factor analysis was done using uni and multivariate analysis. Results A total of 34 patients were treated (M:F = 1:2.3). The distal group significantly showed poor clinical grade at presentation (n = 9, 47.4%) in contrast to (n = 2, 13.3%) proximal aneurysms (p = 0.039). Despite an overall tendency for a delayed functional improvement in these patients, the results were mainly due to favorable outcomes in the proximal group (favourable functional outcomes at discharge and at last follow-up being 80% and 86.7% respectively). On multivariate analysis, only WFNS grade (> 2) at presentation (OR = 13.75; 95CI = 1.2–157.7) (p = 0.035) and application of temporary clips (AOR = 34.32; 95CI = 2.59–454.1) (p = 0.007), both of which were more in the distal group, independently predicted a poor long term functional outcome. Conclusion Aneurysm location impacts preoperative clinical grade and affects intraoperative aneurysm rupture risk rate as well as temporary clipping requirement. The combination of these leads to worse short and long-term functional outcomes in distal DACA aneurysms.

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“…Recently marketed low-profile flow diverters (FDs) are recommended in selected distal vascular pedicle and bifurcation aneurysms [ 4 , 5 ]. The Flow Re-Direction Endoluminal Device Junior-FRED Jr (MicroVention, Tustin, California) is one of the low-profile FDs dedicated for distally located aneurysms whose parent vessel diameter is less than 3 mm [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

Endovascular treatment of challenging aneurysms with FRED Jr flow diverter stents: a single-center experience

et al. 2022

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Purpose To analyze clinical safety and efficacy of flow re-direction endoluminal device (FRED) Jr flow diverter for treatment of unruptured, ruptured, or recanalyzed aneurysms. Materials and methods Between October 2019 and February 2022, 25 patients with 31 aneurysms treated with FRED Jr were included in the study. Clinical and radiological records, procedural details, and follow-up outcomes were retrospectively evaluated. Eighteen (72%) patients were female. Median age was 48.8 (age range 9–85). Mean follow-up was 21 months (6–28 months). Location of the aneurysms were as follows; 13 in middle cerebral artery (MCA), 7 in anterior cerebral artery (ACA), 4 in posterior cerebral artery (PCA), 3 in true posterior communicating artery (PCom), 2 in anterior communicating artery (ACom), 1 in superior cerebellar artery (SCA), 1 in true ophthalmic artery. Five patients (20%) presented with acute subarachnoid hemorrhage (aSAH). Results In all procedures, FRED Jr was successfully deployed. Three true Pcom aneurysms and a true ophthalmic aneurysm were treated with FRED Jr. Three patients with two adjacent aneurysms were treated with a single FRED Jr. In two (8%) patients in-stent thrombosis occurred intraoperatively, they were treated with iv tirofiban and thrombectomy without any sequelae. Post-discharge 2 weeks later, intraparenchymal hemorrhage occurred in a patient. He was treated with surgical drainage, the clinical course was modified Rankin score (mRS) 2. Digital subtraction angiography (DSA) was performed on 16 (64%) patients with 21 (67%) aneurysms. Near complete–complete occlusion (O’Kelly–Morata grading scale (OKM C-D) was documented in 15/16 (93.7%) patients, 20/21 (95.2%) aneurysms. In nine (36%) patients, no residual filling was observed in the magnetic resonance angiography (MRA). Good clinical outcome (mRS 0–1) was achieved in 24/25 (96%) of patients. Conclusion Endovascular treatment of small cerebral aneurysms with FRED Jr is safe and effective even in complex and challenging morphologies allowing high rates of aneurysm occlusion with low periprocedural complications. Our cohort, consisting of a rate 20% acute ruptured aneurysms, is the major additive data to the published literature.

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Contemporary Management of Distal Anterior Cerebral Artery Aneurysms: A Dual-Trained Neurosurgeon's Perspective

Cited by 11 publications

References 22 publications

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

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

Under recognized yet a clinically relevant impact of aneurysm location in Distal Anterior Cerebral Artery (DACA) aneurysms: insights from a contemporary surgical experience

Endovascular treatment of challenging aneurysms with FRED Jr flow diverter stents: a single-center experience

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