Endovascular Management of Distal ACA Aneurysms: Single-Institution Clinical Experience in 22 Consecutive Patients and Literature Review

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Fig 1.
A, Initial CT scan of Patient 9 (Fisher grade IV). B, CT angiogram showed a 2.8-mm aneurysm. The patient underwent coil embolization. Preprocedural (C) and postprocedural (D) angiograms. Three coils were delivered. Complete occlusion was achieved. Used with permission from Barrow Neurological Institute.
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Fig 2.
A, Angiogram of a ruptured distal ACA aneurysm in Patient 12 reveals a 3-mm aneurysm arising from the A3 segment. B, Lateral view of a selective injection of the right pericallosal artery after coiling. The aneurysm was packed with 2 coils. Total occlusion was achieved. Used with permission from Barrow Neurological Institute.
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Fig 3.
Recurrence was observed in 2 of 13 patients who underwent follow-up angiography in our institution. Anteroposterior (A) and lateral (B) angiography at 5 months of a 69-year-old woman diagnosed with a 20-mm unruptured distal ACA aneurysm who underwent uneventful coiling. The aneurysm regrew after coil compaction to almost the initial size. Anteroposterior (C) and lateral (D) projections immediately after retreatment. Total occlusion was obtained. Used with permission from Barrow Neurological Institute.

Table 1:

Demographics, outcomes, and mortality rates from 7 endovascular series of distal ACA aneurysms

Reference	No. Pts.	No. Ruptured	HH Grade (%)			Mean Aneurysm Size ± Range (mm)	Immediate Occlusion: no. (%)	Immediate Near-Occlusion or Better (90%–100%)	Overall Favorable Outcome (%)	Favorable Outcome Unruptured (%)	Favorable Outcome HH I–II (%)	Favorable Outcome HH III–V (%)	Mortality: Ruptured Aneurysms (%)
Reference	No. Pts.	No. Ruptured	I–II	III	IV–V	Mean Aneurysm Size ± Range (mm)	Immediate Occlusion: no. (%)	Immediate Near-Occlusion or Better (90%–100%)	Overall Favorable Outcome (%)	Favorable Outcome Unruptured (%)	Favorable Outcome HH I–II (%)	Favorable Outcome HH III–V (%)	Mortality: Ruptured Aneurysms (%)
Menovsky et al, 2002¹⁰	12	12	58.3	25	16.7	5.7 ± 2.8	11 (91.7)	12 (100)	100	−	100	100	0
Keston et al, 2004¹³	18	17	88.2	5.9	5.9	−	9 (52.9)	14 (82.3)	100	100	100	100	0
Nguyen et al, 2007¹⁷	25	12	−	−	−	7.5	20 (74)	N/A	88	−	−	−	16.7
Pandey et al, 2007¹⁶	28	27	48.2	22.2	29.6	5.5	25 (89.3)	26 (92.9)	67.9	100	84.6	50	3.7
Waldenberger et al, 2008¹⁵	29	21	33.3	33.3	33.3	5.4 ± 3	27 (93)	27 (93)	59	85.7	85.7	12.5	28.6
Vora et al, 2010¹⁸	26	13	46.2	38.5	15.4	5.7 ± 2.8	15 (57.7)	22 (84.6)	64.2	92.3	66.7	33.3	15.4
Current series	22	13	46.2	7.7	46.2	7.5 ± 5.6	11 (50)	21 (95.5)	77.3	88.9	83.3	57.1	0

Table 2:

Demographics, outcomes, and mortality rates from microsurgical clipping series of distal ACA aneurysms

Reference	No. Pts.	No. Ruptured	HH Grade (%)			Mean Aneurysm Size (mm)	Favorable Outcome (GOS 4 or 5)				Mortality: Ruptured Aneurysms (%)
Reference	No. Pts.	No. Ruptured	I–II	III	IV–V	Mean Aneurysm Size (mm)	Overall (%)	Unruptured (%)	HH I–II (%)	HH III–V (%)	Mortality: Ruptured Aneurysms (%)
Proust et al, 1997²	43	35	42.9	25.7	31.4	−	69.8	87.5	80	55	14.3
de Sousa et al, 1999¹	72	65	69.2	1.5	29.2	–	84.7	100	88.9	70	7.7
Steven et al, 2007⁸	59	36	36.1	36.1	27.7	7.9	71.2	91.3	92.3	39.1	16.7
Lehecka et al, 2007²⁵	62	258	48.9	18.5	32.6	4.8^*	78.2	86.5	90.2	58.6	13

↵* Value corresponds to all 470 patients in that study, including conservatively managed cases.

Table 3:

Summary of clinical and radiologic data of 13 patients with ruptured distal ACA aneurysms undergoing coiling

Patient	Age/Sex	HH Grade	Fisher Grade	ICH	Associated Aneurysms Elsewhere	Initial Occlusion (%)	Initial GOS	Final GOS	Follow-Up (months)	Complications
1^{^a}	53/F	IV	IV	Yes	−	100	3	5	50	−
2	74/F	II	III	No	−	>95	4	−	0	−
3	39/F	I	III	No	1	>95	5	5	48	Retroperitoneal hematoma^{^b}
4	40/F	IV	IV	Yes	−	95	2	−	0	−
5	59/F	I	III	No	2	100	5	−	0	−
6	32/M	II	III	No	−	100	5	5	5	−
7	51/M	II	IV	Yes	7	100	3	3	25	−
8	63/F	III	IV	No	1	95	5	5	6	−
9	76/M	IV	IV	Yes	1	100	2	−	0	−
10	72/F	IV	IV	Yes	4	100	4	4	3	−
11	51/M	V	IV	No	−	90	2	−	0	Thrombus formation^{^c}
12	54/F	IV	IV	No	−	100	4	5	11	Thrombus formation^{^c}
13	68/F	I	III	No	2	>95	5	5	1.5	−

F indicates female; M, male; ICH, intracerebral hematoma.
↵a Patient had 2 recurrences, one after 4 months and a second after 3 years. Both were recoiled. One-year follow-up angiogram confirmed complete occlusion.
↵b Conservative management.
↵c Abciximab infusion reversed thrombus formation.

Table 4:

Summary of clinical and radiologic data of 9 patients with unruptured distal ACA aneurysms undergoing coiling

Patient	Age/Sex	Cause of Investigation	Associated Aneurysms Elsewhere	Initial Occlusion (%)	Initial GOS	Final GOS	F/U (months)	Complications
14^{^a}	69/M	TIA + seizures	−	100	3	5	62	Thrombus formation^{^b}
15	63/M	Polycystic kidney disease	−	>95	5	5	39	Thrombus formation^{^b}
16	62/F	Incidental/headache	3	100	5	5	12	−
17	55/M	Posttraumatic headache	2	>95	5	5	14	−
18	50/F	Lightheadedness, dizziness	−	100	5	5	16	−
19	62/F	Family history, syncope	2	<90	3	3	1.5	Intraprocedural rupture
20	44/F	History of SAH/MCA clipping 1.5 y before	2	95	5	5	8	−
21	60/F	Syncope	−	100	5	5	12	−
22	87/M	TIA	−	>95	5	5	1.5	−

F/U indicates follow-up; MCA, middle cerebral artery; SAH, subarachnoid hemorrhage; TIA, transient ischemic attack.
↵a Patient had recurrence on MR angiography 5 months after coiling. Aneurysm was recoiled, and complete occlusion was observed during entire follow-up.
↵b Abciximab infusion shrunk and stabilized the thrombotic formations.

Table 5:

Summary of characteristics of 22 distal ACA aneurysms

Characteristic	Ruptured	Unruptured
Size (mm)
Mean ± SD (range)	6.2 ± 3.2 (2.8–12)	9.2 ± 7.8 (3–25)
<7	7	5
7–14	6	2
14–25	−	1
>25	−	1
Location
A2	3	2
A3	10	6
A4/5	−	1
Origin at a branching point
Anterior internal frontal artery	2	−
Callosomarginal artery	7	5