The researchers say a prospective, multicenter trial with rigorous postprocedural imaging and neuropsychological testing is warranted.
During coil embolization of anterior communicating artery (ACoA) aneurysms, compromise of the parent artery does not appear to confer additional risk and may even protect against recanalization, provided A1 flows are symmetric, according to a study recently published online ahead of print in Stroke.
“Infringement on parent arteries during coil embolization is usually contraindicated, given the risk of severe ischemic complications,” write the authors, led by Hyun Ho Choi, MD (Chung-Ang University College of Medicine, Seoul, South Korea). “However, unlike aneurysms in other locations, those in the ACoA may benefit from ACoA compromise if sufficient A1 flow to each A2 vessel is confirmed.”
Choi and colleagues examined outcomes of 285 aneurysms with symmetric A1 flows treated at their institution via endovascular coil embolization, with and without ACoA compromise, between October 2012 and July 2017.
Overall, treatment involved ACoA compromise in 71 aneurysms (24.9%), with complete compromise in 15 and incomplete compromise in 56. The ACoA was preserved in the remaining lesions.
Nine patients experienced procedure-related thromboembolisms, including four with and five without ACoA compromise. Thromboembolisms were asymptomatic in all but one patient with ACoA compromise. The rate of intraprocedural leakage was 1.1%, with all three instances in patients with preserved ACoAs. Six patients had poor functional outcomes (mRS score > 2) attributable to poor status of subarachnoid hemorrhage in ruptured aneurysms.
Low Risk, Favorable Outcome
Multivariate analysis revealed that subarachnoid hemorrhage at presentation alone was an independent risk factor for thromboembolism (OR 15.98; 95% CI 3.64-69.40). ACoA compromise was statistically unrelated.
Among 276 aneurysms with more than 6 months of follow-up (mean 20.9 ± 13.1 months), recanalization was confirmed in 21 (minor in 15 and major in six). A narrow saccular neck (≤ 4 mm) and ACoA compromise were independently associated with prevention of recanalization (P < 0.01 and P = 0.04, respectively).
“Results of this retrospective review suggest that ACoA compromise carries a low complication rate and achieves favorable clinical outcomes, with stable occlusion,” conclude the authors. “This approach may be a valid alternative for coil embolization of ACoA aneurysms if symmetric A1 flows are confirmed.”
Choi and colleagues say the mechanism for the benefit of ACoA compromise remains unclear. “We suspected that ACoA compromise might help compact the coil packed at the base of aneurysms, thus reducing intrasaccular flow and impeding recanalization,” they write.
They acknowledge, however, that the single-center, retrospective nature of this study is an important limitation. Additionally, the decision to compromise the ACoA was based on perceived procedural necessity, not previously identified indications. Choi et al recommend that this approach be evaluated in a multicenter, prospective trial that includes routine postprocedural MRI, follow-up digital subtraction angiography, and formal neuropsychological testing.
Choi HH, Cho YD, Yoo DH, et al. . J Neurosurg. 2019;Epub ahead of print.
Choi reports no relevant conflicts of interest.