Introduction Anterior communicating artery (Acom) aneurysm rupture and treatment is associated with cognitive and behavioral deficits after recovery. The cause of these neuropsychiatric deficits remains uncertain, but prior studies have suggested ischemic injury to the frontal cortex or striatum as a possible etiology. Surgical clipping of anterior communicating artery aneurysms has been associated with more severe cognitive and behavioral deficits when compared to endovascular coil embolization. We characterized patterns of cerebral ischemic injury and patient outcomes following treatment of ruptured Acom aneurysms by clipping or coil embolization.
Materials and methods We retrospectively reviewed 100 consecutively treated patients with ruptured anterior communicating artery aneurysms (50 clipped- Group 1 and 50 coiled- Group 2) presenting to our neurovascular referral center. Patient demographic, treatment, and outcome data were determined by electronic medical record review. Neuroimaging studies including CT, CTA, MRI, MRA, and DSA were reviewed for aneurysm characteristics and associated intraparenchymal hemorrhage, ischemic, and vasospasm related cerebral injury. Statistical analysis was performed using XLSTAT and SPSS; a p-value of 0.05 was considered significant.
Results Group 1 patients (coil embolization) were older (mean age 56 years vs. 51; p = 0.04) and presented with a worse clinical status (60% with Hunt and Hess Score greater than 2 vs. 34% in clipping group; p = 0.009). There were no differences in sex, hypertension, hyperlipidemia, diabetes, coronary artery disease, smoking, illicit drug use, alcohol abuse, or family history of aneurysms between these two groups. There was a trend toward worse cerebral infarction burden in the surgical group (p = 0.06), and cerebral infarction in the territory of the recurrent artery of Heubner was more common in the clipping group (33% compared to 2%; p = 0.0005). In a multivariate analysis, poor outcome (mRS greater than 2) was associated with diabetes mellitus (p = 0.04), presentation with Hunt and Hess greater than 2 (p = 0.02), age over 55 years (p = 0.004), and the development of cerebral arterial vasospasm (p = 0.0001). However, no differences in mortality, discharge modified Rankin score (mRS), or 3-month follow-up mRS were detected between the two groups.
Conclusions Diabetes mellitus, presentation with Hunt and Hess subarachnoid hemorrhage greater than 2, age over 55, and the development of cerebral arterial vasospasm were associated with worse outcomes following ruptured Acom aneurysm treatment. Although patients treated with endovascular coil embolization were older and more likely to present with Hunt and Hess subarachnoid hemorrhage greater than 2, there was no differences in clinical outcome when compared to patients treated with microsurgical clipping at discharge or at 3-months. Recurrent artery of Heubner cerebral infarction is more common after surgical clipping of ruptured ACom aneurysms. Further studies are warranted to determine if post-surgical artery of Heubner infarctions contribute to cognitive and behavioral deficits after treatment of ruptured Acom aneurysms.
Disclosures J. Heit: None. N. Telischak: None. H. Do: None. R. Dodd: None. G. Steinberg: None. S. Chang: None. M. Marks: None.
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