Microsurgical Treatment of Unruptured Anterior Communicating Artery Aneurysms: Approaches and Outcomes in a Large Contemporary Series and Review of the Literature.

Background: With advances in endovascular techniques, the relative roles of microsurgery and endovascular therapy in the management of intracranial aneurysms have become less clear, and data regarding treatment-specific outcomes are increasingly important.
Objective: To describe our experience with microsurgery in a large series of unruptured anterior communicating artery aneurysms (ACOMMAAs) and detail our treatment decision-making process based on individual aneurysm morphology.
Methods: We retrospectively reviewed unruptured ACOMMAAs treated microsurgically at our center between 1997 and 2018, recording aneurysm size, surgical approach, occlusion rates, neurological outcomes, and complications.
Results: We treated 300 unruptured ACOMMAAs in 300 patients, mean age 49 yr, 180 (60.0%) female, including 245 (81.7%) small, 50 (16.7%) large, and 5 (1.7%) giant aneurysms. Most underwent a pterional approach (253, 84.3%), with orbitozygomatic or anterior interhemispheric approaches in 35 (11.7%) and 12 (4%), respectively. Greater than 95% occlusion was achieved in 284 (94.7%), 90% to 95% occlusion in 13 (4.3%), and 3 (1.0%) underwent wrapping. Serious complications occurred in 3 patients (1.0%) resulting in 2 deaths (0.7%), and minor complications in 12 (4.0%). At final follow-up, good neurological outcome was observed in 297 (99.0%) patients.
Conclusion: Given clinical equipoise regarding optimal treatment of unruptured ACOMMAAs, this work provides a benchmark for achievable microsurgical outcomes. Future surgical/endovascular studies should separate results of ruptured and unruptured lesions and describe aneurysm morphology to allow for better comparison of outcomes between treatments. We suggest that open microsurgery represents an important option for select, morphologically complex ACOMMAAs, and that a multidisciplinary approach offers optimal patient outcomes.
(Copyright © 2020 by the Congress of Neurological Surgeons.)