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  • Failure of Previously Coiled Anterior Communicating Artery Aneurysms: Incidence and Predictors of Subsequent Clipping

    Final Number:

    Elias Atallah MD; Sage Rahm; Carrie Andrews; Nohra Chalouhi MD; Stavropoula I. Tjoumakaris MD; Nabeel Herial MD; M. Reid Gooch MD; Robert H. Rosenwasser MD, FACS, FAHA; Hekmat Zarzour; Pascal Jabbour MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Anterior communicating artery aneurysms (AComA) represent the most common site of cerebral aneurysm formation and rupture. Ruptured AComAs often produce disabling cognitive deficits that may result in patient’s incapacitation. Significant rates of aneurysm recurrence have been reported with coiled AComAs. We aimed to quantify the rates and the predictors of recurring coiled AComAs, and the subsequent need for irrevocable surgical treatment.

    Methods: We performed a retrospective cohort study of 521consecutive patients treated in our center for their AComAs. Patients’ electronic medical charts were reviewed between 2004 and 2016. Patients were cared for by dually trained neurovascular surgeons. Data on aneurysm characteristics, occlusion rates, recurrence rates, aneurysm re-rupture, and clipping with subsequent frontal and striatal infarct, was collected.

    Results: Of 521patients who were coiled for their AcomAs, 57patients(11%; mean-age 49yo[SD=11]; females56%) had failed treatment with depicted aneurysm persistent filling(n=2, 3.5%) or recurrence(n=55, 96.5%) on follow/up angiography. 30/57(52.6%)patients continued to smoke. Aneurysm projection in a sagital plane was as follows: 14anteriorly, 10posteriorly, 20superiorly, 13inferiorly. Average aneurysm size was5.8mm(SD=2.4). 89.5%(51/57)presented initially with a ruptured AComA. Average aneurysm occlusion after primary coil deployment was96%(SD=8). Occlusion rates according to Raymond Roy Scale were as follows: (77%)44/57Class1, (21%)12/57Class2, (1.7%)1/57Class3. Average mRS at discharge was 1.8(SD=1.2). Patients were followed on average for 27.6months(SD=29). The average aneurysm occlusion on latest follow-up angiogram was 69%. Occlusions on follow-up were: (26.3%)15/57Class2 and (73.7%)42/57Class3. 2(3.5%)patients re-ruptured their aneurysm. 6(10.5%)patients required re-coiling. All the patients were microsurgically clipped. 6(10.5%)patients had a subsequent frontal infarct. No other complications were clinically sighted (average mRS=1.4[SD=0.8]).

    Conclusions: The recurrence rate of coiled AComAs is not negligible(11%), it should not be perceived as insignificant. It holds an imminent risk of aneurysm re-rupture, threatening with major disability and fatality.

    Patient Care: Wide necked Acom aneurysms, and multi-lobulated complex Acom aneurysms, might have a higher rate of recurrence after initial coiling. To our knowledge, this is a pilot study of the predictors of coiled AcomAs refilling, suggesting primary clipping for certain complex aneurysms.

    Learning Objectives: We recommend the selection of certain AcomA’s for a primary clipping rather than coiling as a permanent and conclusive modality of treatment.


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