Anterior circulation intracranial aneurysm

• Early experience using optical coherence tomography for intraluminal evaluation of vascular healing associated with endovascular treatment of intracranial aneurysms
• Treatment and outcomes of concomitant parasellar meningiomas and anterior circulation aneurysms: a systematic review and perspective in the endovascular era
• Flow Diversion Versus Coiling in Small and Medium-sized Unruptured Aneurysms of Proximal Anterior Circulation with Complex Anatomy: a Matched-pairs Study
• Five aneurysms in the posterior circulation associated with moyamoya disease: illustrative case
• Intracranial Aneurysms in Autosomal Dominant Polycystic Kidney Disease: A Practical Approach to Screening and Management
• Delayed destabilization and rupture of a giant anterior circulation aneurysm following flow-diverter placement: A case report
• Perianeurysmal cyst formation post embolization and its management: case presentation and systematic review of an uncommon entity
• Midterm outcomes and costs of Pipeline embolization device alone versus Atlas stent-assisted coiling for unruptured anterior circulation aneurysms: a propensity score matched comparative analysis

Intracranial aneurysm of the anterior circulation.

Internal carotid artery aneurysm.

Posterior communicating artery aneurysm.

Middle cerebral artery aneurysm.

Anterior communicating artery aneurysm.

Ophthalmic artery aneurysm.

Pericallosal artery aneurysm.

Anterior cerebral artery aneurysm

Middle cerebral artery aneurysm

Approximately 90% of intracranial aneurysm arise from the anterior circulation.

Anterior cerebral artery aneurysm (ACA) / Anterior communicating artery aneurysm (ACoA complex): ~30-40%

Supraclinioid internal carotid artery aneurysm ICA and ICA / posterior communicating artery aneurysm (PCoA junction): ~30%

Middle cerebral artery aneurysm (MCA) (M1/M2 junction) bi/trifurcation: ~ 20-30%.

Small anterior circulation intracranial aneurysm

Aneurysms of the anterior circulation larger than 2cm have a complex relationship to the anterior skull base, requiring a multi-modality management approach.

In a retrospective study of 54 patients with such aneurysms who underwent clipping between 2001 and 2012 analyzes clinical and surgical data, aneurysm characteristics and correlates them with respect to the Glasgow outcome score at follow-up and immediate post-operative clinical status.

Patients with an outcome score of 5 or 4 were categorized as “good”, while those with score 3-1 were “poor”. Fisher's exact test and paired T-test (p<0.5) were used to test statistical significance for discrete and continuous variables respectively.

44 (81.4%) patients had a good outcome. Patients with non-ophthalmic/paraclinoid aneurysms had significantly lower incidence of adverse intra-operative events (p=0.035). Patients older than 50 years (p=0.045), with adverse intra-operative events (p=0.015) and post-operative infarction (p<0.001) had a poor outcome compared to those younger than 50 years age and those without adverse intra-operative events or infarctions. The grouped age variable had maximum influence on patient outcome. Location and size of aneurysm did not have an overall impact on surgical outcome. There were 4 mortalities.

Primary clipping of proximal non-cavernous aneurysms on the internal carotid artery is associated with adverse intra-operative events. A multi-modality treatment approach in these aneurysms should be individualized, more so in patients older than 50 years ¹⁾.

Patients with bilateral anterior circulation aneurysms present a management challenge. These lesions may be treated in a staged manner or alternatively, for select patients, a contralateral approach may be utilized to treat bilateral aneurysms with a single surgery.

According to contemporary data about occlusion rates, functional outcomes, and complications, primary or secondary treatment of LGIAs of the anterior circulation seems justified. Microsurgical occlusion rates are higher in LGIAs. An expert consensus on reporting complications and management strategies is warranted ²⁾

see Endoscope assisted surgery for anterior circulation aneurysm

Pipeline embolization device (PED) can be utilized in the treatment of distal anterior circulation aneurysms with difficult anatomy for conventional surgical or endovascular techniques. Larger-scale studies with long-term follow-up are needed to further elucidate the durability of PED treatment and its effect on perforator-rich vascular segments ³⁾.

Anterior circulation aneurysm case series.

A 57-year-old woman with incidentally discovered bilateral aneurysms (left middle cerebral artery [MCA], left anterior choroidal artery and right MCA). A contralateral approach through a left pterional craniotomy was performed for microsurgical clipping of all three aneurysms. The techniques of pterional craniotomy, contralateral approach, microsurgical clipping and intraoperative angiography are reviewed. The authors are grateful to Wuyang Yang, M.D. for his assistance. The video can be found here: http://youtu.be/MlPIu3hQZkg ⁴⁾.