ORIGINAL

Anterior Communicating Artery Aneurysms: microsurgical clipping and pitfalls. An overview

Aneurismas da Artéria Comunicante Anterior: clipagem microcirúrgica e armadilhas. Visão geral

  • Pedro Henrique Simm Pires de Aguiar (1,2)    Pedro Henrique Simm Pires de Aguiar (1,2)
  • Giovanna Zambo Galafassi (3)
  • João Pedro Magalhães Farias (3)
  • Stephanie Borghi Campos de Moraes (3)
  • Marco Tulio Sette dos Santos (4)
  • Marco Prist (5)
  • Nicole de Palma Gomes (6)
  • Paulo Henrique Pires de Aguiar (7)    Paulo Henrique Pires de Aguiar (7)
  Views: 1242
  Downloads: 33

Resumo

Os autores revisaram os detalhes técnicos da clipagem microcirúrgica de aneurismas da artéria comunicante anterior não rotos. Os detalhes da dissecção são enfatizados, bem como as principais indicações. A discussão dos aspectos anatômicos foi desenvolvida e do tratamento endovascular também foram abordados nesta visão geral. A microcirurgia de aneurismas cerebrais continua sendo um desafio e todos os esforços para manter o conhecimento e os conceitos da abordagem microcirúrgica devem ser preservados, sendo este o objetivo principal deste artigo.

Palavras-chave

Aneurisma da artéria comunicante anterior; Clipagem microcirúrgica; Tratamento endovascular; Diversor de fluxo; Artéria comunicante anterior

Abstract

The authors reviewed the technical details of microsurgical clipping of non ruptured anterior communicating artery aneurysms. Details of the dissection are emphasized as well as the main indications. Discussion of anatomical aspects and landmarks were developed and the endovascular treatment was also concerned in this overview. The microsurgery of brain anterior communicating aneurysms remains a challenge and all efforts to keep the knowledge and concepts of microsurgical approach ought to be preserved, being the main goal of this article.

Keywords

Anterior communicating cerebral artery aneurysm; Microsurgical clipping; Endovascular treatment; Flow divert; Anterior communicating artery

References

1. Pahwa B, Goyal S, Chaurasia B. Understanding anterior communicating artery aneurysms: a bibliometric analysis of top 100 most cited articles. J Cerebrovasc Endovasc Neurosurg. 2022;24(4):325- 34. http://dx.doi.org/10.7461/jcen.2022.E2022.01.001. PMid:36480823.

2. Stehbens WE. Etiology of intracranial berry aneurysms. J Neurosurg. 1989;70(6):823-31. http://dx.doi.org/10.3171/jns.1989.70.6.0823. PMid:2654334.

3. International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms - risk of rupture and risks of surgical intervention. N Engl J Med. 1998;339(24):1725-33. http://dx.doi.org/10.1056/NEJM199812103392401. PMid:9867550.

4. Chen J, Li M, Zhu X, et al. Anterior communicating artery aneurysms: anatomical considerations and microsurgical strategies. Front Neurol. 2020;11:1020. http://dx.doi.org/10.3389/fneur.2020.01020. PMid:33013671.

5. Chen L, Agrawal A, Kato Y, et al. Role of aneurysm projection in “A2” fork orientation for determining the side of surgical approach. Acta Neurochir. 2009;151(8):925-33. http://dx.doi.org/10.1007/s00701- 009-0407-1. PMid:19499172.

6. Ferguson GG. Physical factors in the initiation, growth, and rupture of human intracranial saccular aneurysms. J Neurosurg. 1972;37(6):666- 77. http://dx.doi.org/10.3171/jns.1972.37.6.0666. PMid:4654696.

7. Yaşargil MG. Microsurgery applied to neurosurgery. New York: Academic Press; 1969. Reconstructive and constructive surgery of the cerebral arteries in man; p. 82-150. http://dx.doi.org/10.1016/B978-1- 4832-2756-6.50011-2.

8. Yasargil MG. Microsurgery: microsurgical Anatomy of the Basal Cisterns and Vessels of the Brain, Diagnostic Studies, General Operative Techniques and Pathological Considerations of the Intracranial Aneurysms (Vol. 1). New York: Thieme; 1984. Microsurgical anatomy of the anterior cerebral- anterior communicating artery complex. p. 1-32.

9. Yasargil MG. Microneurosurgery: clinical considerations, surgery of the intracranial aneurysms and results (Vol. 2). New York: Thieme; 1984. Anterior cerebral and anterior communicating artery aneurysms. p. 165-231.

10. Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol. 1975;3(1):7-14. PMid:1111150.

11. Yasargil MG, Fox JL, Ray MW, et al. The operative approach to aneurysms of the anterior communicating artery. In: Enbuhl K, editor. Advances and technical standards in neurosurgery (Vol. 2). New York: Springer; 1975. p. 113-70.

12. Yasui T, Kishi H, Komiyama M, et al. The limitations of three-dimensional CT angiography (3D-CTA) in the diagnosis of cerebral aneurysms. No Shinkei Geka. 2000;28(11):975-81. PMid:11127593.

13. Kirgis HD, Fisher WL, Llewellyn RC, Peebles EM. Aneurysms of the anterior communicating artery and gross anomalies of the circle of Willis. J Neurosurg. 1966;25(1):73-8. http://dx.doi.org/10.3171/ jns.1966.25.1.0073. PMid:5947049.

14. Serizawa T, Saeki N, Yamaura A. Microsurgical anatomy and clinical significance of the anterior communicating artery and its perforating branches. Neurosurgery. 1997;40(6):1211-8. http://dx.doi. org/10.1097/00006123-199706000-00019. PMid:9179894.

15. Okahara M, Kiyosue H, Mori H, Tanoue S, Sainou M, Nagatomi H. Anatomic variations of the cerebral arteries and their embryology: a pictorial review. Eur Radiol. 2002;12(10):2548-61. http://dx.doi. org/10.1007/s00330-001-1286-x. PMid:12271398.

16. Araújo AS Jr, Aguiar PH, Fazzito MM, et al. Prospective factors of temporary arterial occlusion during anterior communicating artery aneurysm repair. Acta Neurochir Suppl. 2015;120:231-5. http://dx.doi. org/10.1007/978-3-319-04981-6_39. PMid:25366629.

17. Leal AG, Ramina R, Aguiar PHP, Fernandes BL, Souza MA, Nohama P. Clinical applications of additive manufacturing models in neurosurgery: a systematic review. Arq Bras Neurocir. 2021;40(4):e349-60. http:// dx.doi.org/10.1055/s-0041-1740646.

18. Shibata E, Takao H, Amemiya S, Ohtomo K. 3D-Printed visceral aneurysm models based on CT data for simulations of endovascular embolization: evaluation of size and shape accuracy. AJR Am J Roentgenol. 2017;209(2):243-7. http://dx.doi.org/10.2214/AJR.16.17694. PMid:28731812.

19. Bhattarai R, Liang C, Chen C, et al. Supraorbital eyebrow keyhole approach for microsurgical management of ruptured anterior communicating artery aneurysm. Exp Ther Med. 2020;20(3):2079-89. http://dx.doi.org/10.3892/etm.2020.8909. PMid:32782520.

20. Figueiredo EG, Deshmukh P, Zabramski JM, et al. Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex. Neurosurgery. 2005;56(Suppl 2):397- 405. PMid:15794836.

21. Rathore L, Yamada Y, Kawase T, Kato Y, Senapati BB. The keyhole approach in anterior circulation aneurysm-current indication and limitation with review of literature. Asian J Neurosurg. 2020;15(2):278- 84. http://dx.doi.org/10.4103/ajns.AJNS_25_19. PMid:32656119.

22. Wen HT, Oliveira E, Tedeschi H, Andrade FC Jr, Rothon AL Jr. The pterional approach: surgical anatomy, operative technique, and rationale. Oper Tech Neurosurg. 2001;4(2):60-72. http://dx.doi.org/10.1053/ otns.2001.25567.

23. Senapati SB, Rathore L, Yamada Y, Kato Y. Interhemispheric approach to anterior communicating artery aneurysm: a case illustration. Asian J Neurosurg. 2019;14(3):946-8. http://dx.doi.org/10.4103/ajns. AJNS_43_19. PMid:31497136.

24. Heiferman DM, Somasundaram A, Alvarado AJ, Zanation AM, Pittman AL, Germanwala AV. The endonasal approach for treatment of cerebral aneurysms: a critical review of the literature. Clin Neurol Neurosurg. 2015;134:91-7. http://dx.doi.org/10.1016/j. clineuro.2015.04.018. PMid:25974398.

25. Sharma AK, Sharma DK. A cadaveric anatomical study on anterior communicating artery aneurysm surgery by extended endoscopic endonasal approach. Asian J Neurosurg. 2020;15(4):908-12. http:// dx.doi.org/10.4103/ajns.AJNS_160_20. PMid:33708661.

26. Kazumata K, Kamiyama H, Ishikawa T, et al. Operative anatomy and classification of the sylvian veins for the distal transsylvian approach. Neurol Med Chir. 2003;43(9):427-34. http://dx.doi.org/10.2176/ nmc.43.427. PMid:14560846.

27. Piske RL, Kanashiro LH, Paschoal E, Agner C, Lima SS, Aguiar PH. Evaluation of Onyx HD-500 embolic system in the treatment of 84 wide-neck intracranial aneurysms. Neurosurgery. 2009;64(5):E865-75. http:// dx.doi.org/10.1227/01.NEU.0000340977.68347.51. PMid:19404128.

28. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2012;43(6):1711-37. http://dx.doi. org/10.1161/STR.0b013e3182587839. PMid:22556195.

29. Aguiar PHP, Maldaun MVC, Panagopoulos AT, et al. Multiple separated and multi-lobular aneurysms of the anterior communicating artery complex. Rev Chil Neurocirug. 2008;30:16-21.

30. Aires R, Galafassi G, Pinho MCV, et al. Preoperative scale proposal based on clinical outcome for elderly patients with ruptured intracranial aneurysms undergoing microsurgery. Int J Neurosci. 2023;133(10):1204- 10. http://dx.doi.org/10.1080/00207454.2022.2070488. PMid:35465825.

31. Hütter BO, Gilsbach JM. Cognitive deficits after rupture and early repair of anterior communicating artery aneurysms. Acta Neurochir. 1992;116(1):6-13. http://dx.doi.org/10.1007/BF01541247. PMid:1615771.

32. Balamurugan S, Agrawal A, Kato Y, Sano H. Intra operative indocyanine gree vídeo-angiography in cerebro vascular surgery: an overview with review of literature. Asian J Neurosurg. 2011;6(2):88-93. http://dx.doi.org/10.4103/1793-5482.92168. PMid:22347330.




1MS, Medical student, Academic internship in Neurosurgery, Serviço de Neurocirurgia, Centro Universitário Faculdade de Medicina ABC, Santo André, SP, Brazil.

2MS, Medical student, Faculdade de Ciências Médicas e Saúde, Pontifícia Universidade Católica de Sorocaba, Sorocaba, SP, Brazil.

3MD, MR, Medical residency in Neurosurgery, Serviço de Neurocirurgia, Centro Universitário Faculdade de Medicina ABC, Santo André, SP, Brazil.

4MD, Adjunct Professor Neurology and Neurosurgery, Faculdade de Medicina ABC, Centro Universitário Faculdade de Medicina ABC, Santo André, SP, Brazil.

5MD, Supervisor of Neurosurgery Service, Hospital Municipal de Santo André, Faculdade de Medicina ABC, Centro Universitário Faculdade de Medicina ABC, Santo André, SP, Brazil.

6MS, Medical student, Centro Universitário Faculdade de Medicina do ABC, Santo André, SP, Brazil.

7MD, PhD, Full Professor of Anatomy, Centro Universitário Faculdade de Medicina do ABC, Santo André, SP, Brazil.

 

Received Jan 2, 2024

Accepted Jan 18, 2024

JBNC  Brazilian Journal of Neurosurgery

  •   ISSN (print version): 0103-5118
  •   e-ISSN (online version): 2446-6786

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