Introduction Approximately 17% of ruptured anterior communicating artery (ACoA) aneurysms were deemed unsuitable for coil embolization during the Barrow Ruptured Aneurysm Trial (BRAT), most commonly due to unfavorable dome-to-neck ratio or diminutive size of the lesion. Only one ACoA aneurysm underwent adjunctive balloon remodeling during BRAT. Advances in endovascular techniques and technology since the trial have allowed for effective treatment of these complex lesions.

Methods All cases of ruptured ACoA aneurysms treated by endovascular modalities from closure of the BRAT in 2007 to 2012 were reviewed for patient and aneurysm characteristics, treatment type, and radiographic outcomes.

Results Ninety-three patients met inclusion criteria, with a mean age of 59.5 + 12.9 years and mean aneurysm size of 6.1 + 2.5 mm. Patients were treated by primary coil embolization (n = 58), balloon-assisted coiling (n = 29), and stent-assisted coiling (n = 6). Thirty (32%) aneurysms were small in largest diameter (<5 mm) and 62 (67%) lesions were wide-necked (dome-to-neck ratio < 2.0). At a mean follow-up of 24.7 + 20.6 months, 51 (55%) lesions were Raymond Class I, 29 (31%) were Class II, and 3 (3%) were Class III, with 23 (25%) patients noted to have improvement in angiographic outcome. Small aneurysms were significantly more likely to achieve Class I outcomes (p = 0.03), whereas there was no association between neck size and angiographic outcome (p = 0.10). Ten (11%) patients underwent retreatment; there was no association between dome or neck size and retreatment (p = 0.16 and 0.10).

Conclusions Since BRAT, the majority of ruptured ACoA aneurysms treated with coil embolization at our institution have been  small lesions or wide-necked. Adjunctive techniques, especially balloon remodeling, are now much more commonly utilized. The majority of these complex aneurysms can achieve good angiographic outcomes with acceptable retreatment rates.

Disclosures K. Moon: None. M. Levitt: None. M. Park: None. F. Albuquerque: None. C. McDougall: None.