gms | German Medical Science

Objective: Temporary artery occlusion (TAO) to provide proximal control and facilitate aneurysm dissection may cause ischemic brain injury. In our department, anterior communicating artery aneurysms (AcomA) are preferentially treated by a right-sided approach regardless of vessel dominance. In cases with a dominant contralateral anterior cerebral artery (A1) and in the majority of cases with a non-inferior projection of the aneurysm dome, early temporary artery occlusion (TAO) of the contralateral A1 is preferred. The aim of this study was to evaluate the safety of this strategy.

Methods: We performed a retrospective analysis of 91 AcomA surgeries including unruptured (n=35, 32%) and ruptured aneurysms. "Early" TAO was defined as systematic contralateral TAO during the initial phase of the dissection (immediately following opening of the chiasmatic cistern and exposure of the contralateral optic nerve), often involving the dominant A1. "Late" TAO corresponds to the occlusion of one or both A1 during the crucial steps of dissection only. The primary outcome was the infarction rate in the territory of the anterior cerebral arteries, defined as new hypodensity on CT scans within 48 hours after surgery.

Results: In a seven-year period, n=91 patients were surgically treated for AcomA. N=10 patients underwent a left-sided approach due to various reasons (additional left-sided aneurysms, etc.) and were excluded from the analysis. From all cases, n=38 patients (46.9%) showed a dominant contralateral A1. In n=35 patients (43.2%) early TAO of the contralateral A1 was performed (mean 25.7 minutes). Of the 38 patients with a dominant contralateral A1, n=18 (47.4%) received early TAO (mean 24.3 minutes). An additional occlusion involving both A1 was performed in n=23 patients during various steps of the dissection. N=6 (7.4%) patients showed new ischemic lesions in the dependent vascular territory after surgery. All were treated for a ruptured aneurysm (p=0.03). 5 of 6 patients received TAO during surgery (83.3%, p=0.66), three underwent early TAO, one involving the dominant A1. There was no statistically significant difference in the rate of infarction between patients with early vs late TAO (p=1).

Conclusion: A right-sided pterional approach with early temporary artery occlusion of the contralateral A1 does not lead to a statistically significant higher rate of cerebral ischemia in the dependent vascular territory and seems to be a safe treatment strategy.