Combination of neuroendoscopic hematoma evacuation and endovascular coil embolization for a ruptured anterior choroidal artery aneurysm in patients with moyamoya disease: illustrative cases.

BACKGROUND: The treatment strategy for hemorrhagic moyamoya disease (MMD) due to a ruptured aneurysm at the distal portion of the anterior choroidal artery remains controversial. The authors successfully treated the ruptured aneurysm with neuroendoscopic hematoma evacuation, followed by endovascular coil embolization. OBSERVATIONS: The authors encountered two patients with massive hemorrhagic MMD whose MMD had already been diagnosed and who had a periventricular anastomosis due to a ruptured aneurysm of the distal portion of the anterior choroidal artery involving the periventricular anastomosis. In both cases, neuroendoscopic hematoma evacuation was performed for hemorrhagic MMD in the acute phase, followed by endovascular coil embolization of the ruptured aneurysm in the chronic phase. In both endovascular treatments, the patient's condition was stabilized by hematoma evacuation, allowing a detailed preoperative evaluation of the anatomical findings of the vessel and functional findings of intraoperative neurophysiological monitoring using continuous monitoring of motor evoked potentials to preserve motor function. LESSONS: Combination therapy can be useful for hemorrhagic MMD in patients with diagnosed MMD with a periventricular anastomosis. Additionally, a preoperative understanding of the vascular construction and intraoperative neurophysiological monitoring will aid in the successful coil embolization of aneurysms at the distal portion of the anterior choroidal artery with hemorrhagic MMD.

Comparison of outcomes between clipping and endovascular coiling in anterior choroidal artery aneurysm: a systematic review.

SAH (subarachnoid hemorrhage) caused by aneurysm rupture has the greatest mortality rate, with nearly 50% of patients unable to survive beyond 1 month after the attack. Anterior choroidal artery (AChA) aneurysms are one of the most difficult to treat among the numerous types of aneurysms. Until now, some neurosurgeons employed shearing while others employed coiling. In this trial, researchers will compare surgical clipping and endovascular coiling treatments for anterior choroidal artery aneurysms in terms of mortality, rebleeding, retreatment, and post-procedure outcomes. Using the PubMed electronic database, the Cochrane library, the Medline Database, the Directory of Open Access Journals, and EBSCHOHOST, a systematic review compared surgical clipping and endovascular coiling in all cases of choroidal artery aneurysm. There were 17 studies that met the eligibility requirements, with a total of 1486 patients divided into groups that underwent clipping (1106) or endovascular coiling (380). The mortality rate for clipping is 1.8%, while the mortality rate for endovascular coiling is 2.34%. Rebleeding occurs in 0% of patients undergoing endovascular coiling and 0.73% of patients undergoing clipping. Retreatment of clipping was 0.27%, while endovascular coiling was 3.42%. Post-complication procedures occurred in 11.12% of patients undergoing endovascular clipping and 15.78% of patients undergoing endovascular coiling. The intervention technique of clipping has a reduced rate of mortality, reoperation, and post-operative complications. Endovascular coiling results in a reduced rate of rebleeding than clipping.

Treatment results of anterior choroidal artery aneurysms treated mostly with coil embolization: A single-center experience.

BACKGROUND: Anterior choroidal artery (AchA) aneurysms are usually small in diameter because of the size of the involved artery and are often wide-necked. Coil embolization of AchA aneurysm is thus challenging because of serious risks, such as thromboembolic occlusion of artery and perforation of aneurysm dome. Therefore, aneurysmal neck clipping remains widely performed despite a recent increase in the use of coil embolization for aneurysm treatment. We report the treatment results of AchA aneurysms mostly (92.3%) treated with coil embolization at our institute. METHODS: The database and medical records of patients who underwent coil embolization for AchA aneurysms were retrospectively analyzed. The clinical and imaging results and procedure-related complications were investigated after coil embolization performed between January 2006 and March 2022 at our institute. RESULTS: In total, 96 AchA aneurysms comprising 65 unruptured and 31 ruptured aneurysms, including only 1 ruptured aneurysm (1.0%) re-embolized at postoperative day 192 because of coil compaction, were evaluated. After the initial coil embolization, complete occlusion was attained in 41, residual neck in 45, and residual aneurysm in 10 patients. Follow-up radiological studies after 6-174 months were performed for 80 aneurysms. Complete occlusion was noted in 57 patients, residual neck in 22, and residual aneurysm in 1. The dysarthria experienced by one (1.0%) patient was the only symptomatic procedure-related complication. After coil embolization, neither delayed new rupture nor re-rupture was observed. CONCLUSIONS: The results of this study demonstrate that coil embolization is a safe and effective treatment option for patients with AchA aneurysms.

A New Classification of Anterior Choroidal Artery Aneurysms and Its Clinical Application.

Background and Purpose: The aim of this study was to compare the different subtypes of anterior choroidal artery (AChoA) aneurysm based on a new classification and to analyze the risk factors according to individual endovascular treatment (EVT). Methods: In the new classification, AChoA aneurysms are classified into independent type (I type) and dependent type (II type) based on the relationship between the AChoA and the aneurysm. II type aneurysms have three subtypes, IIa (neck), IIb (body), and IIc (direct). We retrospectively analyzed 52 cases of AChoA aneurysm treated in our center between 2015 to 2019. There were 13 (25.0%) I type aneurysms, 24 (46.2%) IIa aneurysms, 15 (28.8%) IIb aneurysms, and no IIc type; 28 cases had a subarachnoid hemorrhage. According to our preoperative EVT plan for the different subtypes: II type should achieve Raymond-Roy Occlusion Class 1 (RROC 1) where possible. To protect the AChoA, it is best to preserve the neck of the IIa type aneurysms (RROC 2), and RROC 3 is enough for IIb type. Results: Ten asymptomatic cases with minimal aneurysms were treated conservatively. Of the other cases, 42 were treated with individualized EVT (26 with a simple coil, 6 with balloon-assisted coiling, 7 with stent-assisted coiling, and 3 by flow diverter. Different subtypes had different RROC (Z = 14.026, P = 0.001). IIb type aneurysms (χ2 = 7.54, P = 0.023) were one of the factors related to temporary or permanent AChoA injury during surgery. Overall, two patients (IIa = 1, IIb = 1) developed contralateral hemiparesis. Conclusions: The new classification diagram clearly shows the features of all types of AChoA aneurysm and makes EVT planning more explicit. The II type (particularly IIb) was a potential risk factor for AChoA injury.

Anterior Temporal Approach for Clipping Posterior-Projecting Supraclinoid Carotid Artery Aneurysms: A More Lateral Corridor to Better Visualize the Aneurysm Neck and Related Branches.

BACKGROUND: Direct visualization of the aneurysm neck and its related branches during microsurgical clipping of supraclinoid internal carotid artery (SICA) aneurysms using a standard pterional approach may be difficult, especially when aneurysms are posteriorly projected. We evaluated the efficacy and safety of an anterior temporal approach for clipping posterior-projecting SICA aneurysms. METHODS: Between December 2017 and March 2020, 26 patients with posterior-projecting SICA aneurysms who received microsurgical clipping via an anterior temporal approach were retrospectively reviewed. The percentage of complete aneurysm obliteration, intraoperative visualization, and preservation of related branches were evaluated. RESULTS: Aneurysm locations were the posterior communicating artery (PCoA) (internal carotid artery [ICA]-PCoA) in 22 patients (84.6%), the anterior choroidal artery (AChA) (ICA-AChA) in 3 patients (11.5%), and both locations in 1 patient (3.9%). Complete aneurysm obliteration was achieved in all patients. For ICA-PCoA aneurysms in which the PCoA was preoperatively identified, the artery was intraoperatively identified in all cases and preserved 100% after surgery. For ICA-AChA aneurysms, AChAs were intraoperatively identified and preserved in all cases after surgery. Procedural-related infarction was 8.7% for ICA-PCoA aneurysms and 7.7% for all SICA aneurysms. Transient oculomotor nerve palsy was found in 2 patients (7.7%). No postoperative temporal contusion was detected. A good outcome at 3 months after surgery was achieved in 90% of patients for good clinical-grade subarachnoid hemorrhage and unruptured cases. CONCLUSIONS: The anterior temporal approach is safe and effective for clipping SICA aneurysms with posterior projection, with a high preservation rate of the related branches.

Anterior choroidal artery aneurysms could have different symptoms, and outcomes: a report of 3 cases treated endovascularly.

Anterior choroidal artery (AChoA) aneurysms are rare intracranial aneurysms, which are treated with endovascular techniques or surgical clipping procedures. AChoA aneurysm may have variable symptomatologies, clinical courses, and outcomes due to the eloquent territory of the artery. We have presented 3 cases of AChoA aneurysms, which differ from each other and literature by rare oculomotor nerve palsy, antiplatelet treatment complication and near-complete late resolution of the oculomotor nerve palsy. We have tried to share our AChoA case experiences to emphasize the importance of being flexible and adaptable in the diagnosis, treatment and follow up of this rare intracranial aneurysm type.

Microsurgical Clipping of Anterior Choroidal Artery Aneurysms: A Systematic Approach to Reducing Ischemic Complications in an Experience with 146 Patients.

BACKGROUND: Aneurysms of the anterior choroidal artery (AChA) have been associated with high treatment-associated morbidity due to ischemic complications. OBJECTIVE: To report a large clinical experience of microsurgically treated AChA aneurysms and describe a systematic approach to reduce ischemic complications. METHODS: One hundred forty-six patients with AChA aneurysms were retrospectively reviewed from a prospectively maintained database. Clinical characteristics, surgical techniques, clinical outcomes, arterial infarction, and use of intraoperative adjuncts (ie, ultrasonography, indocyanine green videoangiography, and neuromonitoring) were analyzed. RESULTS: In total, one hundred forty-three aneurysms (97.9%) were clipped. Temporary clipping was utilized in 47 cases (32.2%) with mean occlusion time of 5.6 min. Arterial infarction occurred in 12 patients (8.2%). In clipped aneurysms, 90.5% were completely obliterated, 8.8% had minimal residual (<5% of original), and 0.7% were incompletely occluded (>5% of original). Mortality (2.7%) was limited to patients with high-grade subarachnoid hemorrhage. Indocyanine green videoangiography and neuromonitoring altered operative technique in ∼20% of cases. Multivariate logistic regression identified intraoperative rupture as the sole predictor for arterial infarction. CONCLUSION: Open microsurgical clipping remains a safe, effective treatment for AChA aneurysms. Microsurgical technique is paramount in preserving AChA patency and reducing ischemic complications. Despite increasing reliance on qualitative measures of AChA blood flow (videoangiography and ultrasonography) and neurophysiological monitoring, these technologies aid us infrequently. However, these adjuncts provide important safety checks for AChA patency. Temporary clipping must be used judiciously to lower the risk of intraoperative rupture while limiting possible ischemia in the AChA territory.

Ruptured Distal Anterior Choroidal Artery Aneurysm Presenting as Isolated Intraventricular Hemorrhage: Case Report and Comprehensive Review of the Literature.

Distal anterior choroidal artery (AChA) aneurysms are infrequent. We discuss the case of a 59-year-old patient who presented with an isolated intraventricular hemorrhage (IVH) secondary to a ruptured distal AChA aneurysm. Initial noninvasive cerebral computed tomography angiography revealed no evidence of an underlying vascular pathology. The patient underwent further digital subtraction cerebral angiography, which revealed an aneurysm arising from the distal AChA segment. The aneurysm was successfully treated with surgical clip ligation. The current study highlights the importance of considering a ruptured distal AChA aneurysm as a potential source of isolated IVH.

Comparative outcome analysis of anterior choroidal artery aneurysms treated with endovascular coiling or surgical clipping.

BACKGROUND: Treatment of anterior choroidal artery (AChA) aneurysms with endovascular coiling or surgical clipping may increase the risk of ischemic complications owing to the critical territory supplied by the AChA. We analyzed the surgical results of endovascular coiling and surgical clipping for AChA aneurysms performed in a single institution, as well as the role of indocyanine green-videoangiography (ICG-VAG) and motor-evoked potential (MEP). METHODS: We analyzed 50 patients (51 aneurysms; 21 men, 29 women; mean age: 58 years) including 25 with subarachnoid hemorrhage treated with endovascular coiling or surgical clipping between April 1990 and October 2013. The complication rates and clinical outcomes of the coil group (mean follow-up: 61 months) and the clip group (mean follow-up: 121 months) were analyzed with a modified Rankin scale. RESULTS: The overall clinical outcome of the coil group (95%) was better than that of the clip group (85%). Especially, the outcomes in the coil group were better in the first investigated period (1990-2007) (P < 0.05). However, after the introduction of ICG-VAG and MEP, the outcomes in the clip group improved significantly (P = 0.005), and treatment-related complications decreased from 20 to 4.7%. Eleven aneurysms (coil group: 8, clip group: 3) showed small neck remnants but no remarkable regrowth, except for 1 case during the mean follow-up period of 91 months. CONCLUSIONS: Surgical clipping of AChA aneurysms has become safer because of ICG-VAG and MEP monitoring. Coiling and clipping of AChA aneurysms showed good and comparable outcomes with these monitoring methods.

Ruptured True Anterior Choroidal Artery Aneurysm in Cisternal Segment.

BACKGROUND: Rupture of a true anterior choroidal artery (AChA) aneurysm in the cisternal segment is extremely rare, whereas cases of a distal AChA aneurysm associated with moyamoya disease are increasingly reported. CASE DESCRIPTION: A 58-year-old woman presented with a severe headache and vomiting. Computed tomography demonstrated a subarachnoid hemorrhage without intraventricular or intracerebral hemorrhaging. Cerebral angiogram findings revealed a proximal AChA aneurysm mimicking an internal carotid artery aneurysm at the origin of the AChA. Intraoperative findings demonstrated a ruptured aneurysm located on a bend of the proximal AChA in the carotid cistern. Neck clipping of the aneurysm with preservation of the AChA led to a good outcome. CONCLUSIONS: A rare case of ruptured true AChA aneurysm in the cisternal segment, unrelated to moyamoya disease, is presented as a cause of subarachnoid hemorrhage.

Discrepancy between voluntary movement and motor-evoked potentials in evaluation of motor function during clipping of anterior circulation aneurysms.

BACKGROUND: Various modalities have been used to confirm the blood flow through parent arteries or surrounding perforating arteries during surgical aneurysm clipping, including motor-evoked potentials (MEPs), Doppler ultrasound, and indocyanine green videoangiography. Nonetheless, contralateral hemiparesis due to arterial blood flow insufficiency may arise because of false-positive or false-negative errors. By performing controlled intraoperative awakening during aneurysm clipping, we compared patients' voluntary movements with simultaneous MEP. METHODS: Four patients with anterior choroidal artery aneurysms and one patient with a dorsal internal carotid artery aneurysm were included in this study. MEP and intraoperative voluntary movements under awake craniotomy were assessed simultaneously during and after the clipping procedure. RESULTS: Aneurysms were safely and successfully clipped in all patients, with no evidence of postoperative neurological deficits. Voluntary movements and MEP findings did not differ from the control state in three patients. In the other two patients, we observed a discrepancy between MEP amplitudes and voluntary movements. In one patient, deterioration and subsequent improvement in voluntary movements were preceded by MEP amplitude reduction during clipping. In the other patient, MEP amplitude did not change although voluntary movement deteriorated during temporary occlusion of the internal carotid artery. CONCLUSIONS: Intraoperative neurological assessment during aneurysmal clipping under awake craniotomy is feasible and safe, and should be valuable for the assessment of ischemia, especially in the anterior choroidal artery. From a neurophysiologic viewpoint, MEP may be insufficiently sensitive for evaluating voluntary movement under ischemia.

Ischemic Complication of Ruptured Anterior Choroidal Artery Aneurysm / 대한뇌혈관외과학회지

OBJECTIVE: Vasospasm is known to play the key role in determining the prognosis of aneurysmal subarachnoid hemorrhage (SAH). We have experienced a higher incidence of vasospasm in the cases of SAH caused by rupture of an anterior choroidal artery (AChA) aneurysm than aneurysms of other area. The purpose of this study is to analyze the ischemic complications in patients with a ruptured AChA aneurysm. METHODS: We retrospectively reviewed 13 patients who were treated for ruptured AChA aneurysm from 1994 to 2007 at our hospital. The prognosis and complications were analyzed based on the institution's data, gender, age, the Hunt and Hess grade, the Glasgow coma scale, the Glasgow outcome scale, the symptoms and neurological examinations, the medical treatment, the digital subtraction angiography (DSA), the computed tomography (CT) and the magnetic resonance imaging (MRI). RESULTS: Forty-one (6%) out of 678 SAH patients had ischemic complications. Thirteen cases (2%) were caused by rupture of an anterior choroidal artery (AChA) aneurysm and 3 of these 13 cases (23.1%) had ischemic complications. Two of these 3 cases (15.4%) had neurological abnormality. Twelve out of the 13 AchA aneurysms had the saccular form. CONCLUSION: In cases of SAH from ruptured AchA aneurysm, the probability of ischemic complications was higher than that of general aneurysmal SAH. This seems to be due to the thin AChA and that the vascular territory of AChA is the area where ischemic brain damage can occur even by a mild vasospasm. So, when operating on a AChA aneurysm, maximum effort should be done to preserve the AChA. However, in the exceptional case with multiple AChAs, one AChA can be trapped without a definitive neurological deficit.

Oculomotor Nerve Palsy due to Ruptured Multiple Anterior Choroidal Artery Aneurysms

We present a case of acute subarachnoid hemorrhage in a 64-year-old male with sudden onset of left ophthalmoplegia. Cerebral angiography demonstrated a 10mm elongated aneurysmal sac which arose from the left internal carotid-anterior choroidal artery junction. The pterional approach was performed as an early surgery for aneurysm clipping. At operative field, the anterior choroidal artery aneurysm which directed posteromedially and compressed the origin of left oculomotor nerve was confirmed. And the blood blister like-aneurysm was also seen at the superolateral portion of the proximal bifurcation of the internal carotid-anterior choroidal artery. A large anterior choroidal artery aneurysm was clipped and the blood blister like-aneurysm was reinforced. No case report has been previously published describing a ruptured anterior choroidal artery aneurysm accomplished with third cranial nerve palsy. We reported a case of multiple aneurysms of anterior choroidal artery that caused ipsilateral oculomotor nerve palsy.

Oculomotor Nerve Palsy due to Ruptured Multiple Anterior Choroidal Artery Aneurysms

We present a case of acute subarachnoid hemorrhage in a 64-year-old male with sudden onset of left ophthalmoplegia. Cerebral angiography demonstrated a 10mm elongated aneurysmal sac which arose from the left internal carotid-anterior choroidal artery junction. The pterional approach was performed as an early surgery for aneurysm clipping. At operative field, the anterior choroidal artery aneurysm which directed posteromedially and compressed the origin of left oculomotor nerve was confirmed. And the blood blister like-aneurysm was also seen at the superolateral portion of the proximal bifurcation of the internal carotid-anterior choroidal artery. A large anterior choroidal artery aneurysm was clipped and the blood blister like-aneurysm was reinforced. No case report has been previously published describing a ruptured anterior choroidal artery aneurysm accomplished with third cranial nerve palsy. We reported a case of multiple aneurysms of anterior choroidal artery that caused ipsilateral oculomotor nerve palsy.