There are limited data on endovascular treatment (EVT) for anterior cerebral artery (ACA) occlusions. This review focuses on aspects related to ACA EVT: ACA anatomy, clinical and imaging findings, prognosis of ACA stroke, and ACA thrombectomy techniques. The ACA anatomy, and the regions supplied by the ACA, are highly variable; frequent anatomical variants include azygos ACA, triplicated ACA and fenestrations of the anterior communicating artery. ACA occlusions can be classified based on occlusion location, their continuity with other vessel occlusions (isolated ACA occlusion vs ACA occlusion as part of a carotid T occlusion) and etiology (primary—spontaneous ACA occlusion, vs secondary—spontaneous or iatrogenic due to clot fragmentation/migration). Symptoms of ACA stroke differ in severity and nature due to large inter-individual variations in territorial ACA blood supply. Generally, ACA strokes are severely disabling, and the typical clinical hallmark is a motor deficit of the contralateral lower extremity. Advanced imaging (CT perfusion, multiphase CT angiography) increases the likelihood of the correct diagnosis of ACA stroke and should be obtained on routine basis.
Available data for ACA EVT suggest its feasibility and safety while clinical outcomes are often unfavorable with conservative management. Therefore, the potential benefit of EVT seems obvious. An optimized endovascular approach for ACA thrombectomy comprises the development and use of smaller and softer devices that can be delivered through small microcatheters with an optimized vector of force. Ultimately, generating high-level evidence for ACA EVT from randomized trials remains warranted.
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Contributors All authors contributed to the manuscript conception. The first draft of the manuscript was written by JO, PC and MG. RC did a critical revision of the manuscript. All authors contributed equally to the manuscript revisions. All authors read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests MG reports consultancy for Medtronic, Stryker, Microvention, GE Healthcare, Mentice, outside the submitted work; editorial board membership at Stroke (Consulting Editor); and in addition, MG has a patent for systems of acute stroke diagnosis issued and licensed. PC has nothing to disclose. JMO has nothing to disclose. RC reports consultancy and/or proctorship for BALT, Stryker, Microvention, Rapid Medical, Siemens Medical Systems, outside the submitted work.
Provenance and peer review Not commissioned; externally peer reviewed.
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