The purpose of this retrospective study was to investigate outcome predictors for patients of ruptured anterior communicating artery aneurysm. In this study patients with ruptured anterior communicating artery aneurysm managed by surgery in this single institute from January 2011 to June 2017 were included. A uniform management protocol was adopted which included early surgery, post op ICU care and aggressive anti vasospasm treatment.

Methods: Retrospectively data of 124 patients was collected and reviewed. The patients were graded according to WFNS and Modified Fischer scoring, size of aneurysm, projections and outcomes were assessed at the time of discharge and after 3 months on the basis of modified Rankin scale.

Conclusion: This study demonstrated that preoperative score and postoperative Hydrocephalus are the factors determining outcome in patients with ruptured anterior communicating artery aneurysm.

Keywords: Aneurysm, Ruptured Anterior communicating artery aneurysm, Modified Rankin scale, Outcome.

1. Hernesniemi J, Dashti R, Lehecka M, et al. Microneurosurgical management of anterior communicating artery aneurysms. Surg Neurol 2008;70:8–28
2. Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J 3(1): 8-36; 1990.
3. Zhao L, Zhang L, Zhang X, Li Z, Tian L, et al. (2014) An Analysis of 1256 Cases of Sporadic Ruptured Cerebral Aneurysm in a Single Chinese Institution. PLoS ONE 9(1): e85668. doi:10.1371/journal.pone.0085668
4. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgi­cal clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366:809–817.
5. Riina HA, Lemole GM Jr, Spetzler RF. Anterior communicating artery aneurysms. Neurosurgery. 2002 Oct; 51(4):993-996.
6. Brisman JL, Song JK, Newell DW. Cerebral aneurysms. N Engl J Med 2006;355:928–39
7. Forget TR Jr, Benitez R, Veznedaroglu E, et al. A review of size and location of ruptured intracranial aneurysms. Neurosurgery 2001;49:1322–5; discussion 25–6.
8. Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med. 2012;366:2474–2482.
9. Ohashi Y, Horikoshi T, Sugita M, Yagishita T, Nukui H. Size of cerebral aneurysms and related factors in patients with subarachnoid hemorrhage. Surg Neurol. 2004;61:239–245; discussion 245.
10. Kashiwazaki D, Kuroda S; Sapporo SAH Study Group. Size ratio can highly predict rupture risk in intracranial small (<5mm) aneurysms. Stroke. 2013;44:2169–2173.
11. Molyneux AJ, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol. 2009;8:427–433
12. Li H, Pan R, Wang H, et al. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke 2013;44(1):29–37.
13. Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, Lamoureux J, Chagnon M, Roy D. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke. 2003;34:1398–1403.
14. Ambekar S, Madhugiri V, Pandey P, Yavagal DR. Cerebral aneurysm treatment in India: Results of a national survey regarding practice patterns in India. Neurol India 2016;64:62-9.
15. HuangQH,WuYF,XuY, et al. Vascular geometry change because of endovascular stent placement for anterior communicating artery aneurysms. AJNR Am J Neuroradiol 2011;32:1721–25
16. Cherian MP, Pranesh MB, Mehta P, et al. Outcomes of endovascular coiling of anterior communicating artery aneurysms in the early post-rupture period: a prospective analysis. Neurol India 2001;59:218–23
17. Schuette AJ, Hui FK, Spiotta AM, et al. Endovascular therapy of very small aneurysms of the anterior communicating artery: five-fold increased incidence of rupture. Neurosurgery 2011;68:731–37
18. Proust F¹, Debono B, Hannequin D, Gerardin E, Clavier E, Langlois O, Fréger P Treatment of anterior communicating artery aneurysms: complementary aspects of microsurgical and endovascular procedures. . J Neurosurg.2003 Jul;99(1):3-14.
19. Hoh BL¹, Chi YY, Dermott MA, Lipori PJ, Lewis SB. The effect of coiling versus clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the university of Florida. 2009 Apr;64(4):614-9
20. Salas E, Ziyal IM, Bejjani GK, Sekhar LN. Anatomy of the frontotemporal branch of the facial nerve and indications for interfascial dissection. Neurosurgery 43(3): 563-568; 1998.
21. Bazowski P, Gamrot J, Rudnik A, Konopka M: Analysis of selected prognostic factors in patients with ruptured cerebral aneurysms operated-on in the early period. Neurol Neurochir Pol Suppl 1:25-28, 1992.
22. Disney L, Weir B, Grace M: Factors influencing the outcome of aneurysm rupture in poor grade patients: A prospective series. Neurosurgery 23:1-9,1988
23. Kassel NF, Torner JC, Haley EC, Jane JA, Adams HP, Kongable GL: The international cooperative study on the timing of aneurysm surgery, part 1: Overall management results. J Neurosurg 73:18– 36, 1990
24. Kleinpeter G, Lehr S: Is hypertension a major risk factor in aneurysmal subarachnoid hemorrhage? Wien Klin Wochenschr 15:307-314, 2002
25. Lagares A, Gómez PA, Lobato RD, Alén JF, Alday R, Campollo J: Prognostic factors on hospital admission after spontaneous subarachnoid haemorrhage. Acta Neurochir (Wien) 143:665-672, 2001
26. Schöller K, Massmann M, Markl G, Kunz M, Fesl G, Brückmann H, Pfefferkorn T, Tonn JC, Schichor C: Aneurysmal subarachnoid hemorrhage in elderly patients: Long-term outcome and prognostic factors in an interdisciplinary treatment approach. J Neurol 260:1052-1060, 2013
27. Schöller K, Massmann M, Markl G, Kunz M, Fesl G, Brückmann H, Pfefferkorn T, Tonn JC, Schichor C: Aneurysmal subarachnoid hemorrhage in elderly patients: Long-term outcome and prognostic factors in an interdisciplinary treatment approach. J Neurol 260:1052-1060, 2013
28. Shimoda M, Oda S, Tsugane R, Sato O: Prognostic factors in delayed ischaemic deficit with vasospasm in patients undergoing early aneurysm surgery. Br J Neurosurg 11:210-215, 1997
29. Bohnstedt BN, Nguyen HS, Kulwin CG, Shoja MM, Helbig GM, Leipzig TJ, Payner TD, Cohen-Gadol AA: Outcomes for clip ligation and hematoma evacuation associated with 102 patients with ruptured middle cerebral artery aneurysms. World Neurosurg 80:335-341, 2013
30. Gomis P, Rousseaux P, Jolly D, Graftieaux JP: Initial prognostic factors of aneurysmal subarachnoid hemorrhage. Neurochirurgie 40:18-30, 1994
31. Jamjoom A, Jamjoom ZA, Stranjalis G, Cummins B, Torrens M: The outcome of surgery of aneurysmal subarachnoid haemorrhage. Br J Clin Pract 47:136-140, 1993
32. Lin CL, Kwan AL, Howng SL: Surgical outcome of anterior communicating artery aneurysms. Kaohsiung J Med Sci 14:561-568, 1998
33. Vlak MH, Rinkel GJ, Greebe P, Greving JP, Algra A: Lifetime risks for aneurysmal subarachnoid haemorrhage: Multivariable risk stratification. J Neurol Neurosurg Psychiatry 84:619-623, 2013
34. Ohman J, Servo A, Heiskanen O: Risks factors for cerebral infarction in good-grade patients after aneurysmal subarachnoid hemorrhage and surgery: A prospective study. J Neurosurg 74:14- 20, 1991.
35. Shiue I, Arima H, Hankey GJ, Anderson CS: Location and size of ruptured intracranial aneurysm and serious clinical outcomes early after subarachnoid hemorrhage: A population-based study in Australasia. Cerebrovasc Dis 31:573-579, 2011
36. Pedraza S, Méndez-Méndez J: The prognostic value of computerized tomography in acute aneurysmal subarachnoid haemorrhages. Rev Neurol 39:359-363, 2004
37. Piazza P, Lisotto C, Querin F, Morassut S, Pomes A: Usefulness of computerized tomography in the prognosis of subarachnoid hemorrhage. Radiol Med 79:585-589, 1990
38. Rosen DS, Macdonald RL: Grading of subarachnoid hemorrhage: Modification of the world World Federation of Neurosurgical Societies scale on the basis of data for a large series of patients. Neurosurgery 54:566-575, 2004.
39. Lagares A, Gómez PA, Lobato RD, Alén JF, Alday R, Campollo J: Prognostic factors on hospital admission after spontaneous subarachnoid haemorrhage. Acta Neurochir (Wien) 143:665-672, 2001
40. Charpentier C, Audibert G, Guillemin F, Civit T, Ducrocq X, Bracard S, Hepner H, Picard L, Laxenaire MC: Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurismal subarachnoid hemorrhage. Stroke 30:1402-1408, 1999
41. Alemán-Rivera A, Camacho-Gómez A: The results of surgical treatment in 100 patients operated on for intracranial aneurysms of the anterior circulation. Rev Neurol 32:1128-1131, 2001
42. Ostábal MI, Sanz C, Suárez MA, Salvo L, Millastre A: The study of prognostic factors of spontaneous subarachnoid hemorrhage. Rev Neurol 25:58-60, 1997
43. Rosen DS, Macdonald RL: Subarachnoid hemorrhage grading scales: A systematic review. Neurocrit Care 2:110-118, 2005.

Varun Singh Pendro

Senior Resident, Dept. of Neurosurgery