Is an anterior communicating artery (Acom) aneurysm measuring 4x5mm, with mild diffuse vasospasm, indicated for intracranial stent placement using flow diverters?

Management of 4x5mm Anterior Communicating Artery Aneurysm with Mild Diffuse Vasospasm

Flow diverter stent placement is not indicated as first-line treatment for this 4x5mm anterior communicating artery aneurysm with mild diffuse vasospasm. 1, 2

Evaluation of Treatment Options

• Small unruptured aneurysms (4x5mm) generally have lower rupture risk and should be evaluated carefully before any intervention 1
• The presence of mild diffuse vasospasm suggests a recent subarachnoid hemorrhage, which is a contraindication for flow diverter placement in the acute phase 2
• The American Heart Association/American Stroke Association guidelines explicitly state that for patients with aneurysmal subarachnoid hemorrhage from ruptured saccular aneurysms amenable to either primary coiling or clipping, stents or flow diverters should not be used due to higher risk of complications 3

Preferred Treatment Approaches

• For this anterior communicating artery aneurysm, conventional treatment options should be considered first 3:

  • Microsurgical clipping offers more durable protection and may be preferred, especially in younger patients 1
  • Primary coiling without stent assistance should be considered if technically feasible 2

• The presence of vasospasm further complicates management and increases risks with any intervention 1:

  • Vasospasm occurs in approximately 30% of patients with SAH and frequently occurs 7 to 10 days after hemorrhage 1
  • Morbidity and mortality in SAH increases between 10% and 20% after onset of clinical symptoms of delayed cerebral ischemia 1

Risks of Flow Diverter Placement in This Case

• Flow diverters require dual antiplatelet therapy, which carries significant hemorrhagic risk in the setting of recent subarachnoid hemorrhage or with potential need for ventriculostomy 2
• The use of flow diverters in the acute phase of ruptured aneurysms is associated with higher complication rates 2
• Permanent neurological procedure-related complications occur in 7.4% of procedures with stents versus 3.8% in procedures without stents 4
• Procedure-induced mortality is significantly higher with stents (4.6%) compared to non-stent procedures (1.2%) 4

Alternative Endovascular Approaches If Surgery Not Feasible

• If endovascular treatment is necessary and the aneurysm has a wide neck, stent-assisted coiling may be more appropriate than flow diversion 3, 5
• For wide-necked saccular aneurysms not amenable to primary coiling, stent-assisted coiling has shown good outcomes with adequate occlusion rates 5, 6
• Stent-assisted coiling has been associated with lower angiographic recurrence rates (14.9%) compared to coiling alone (33.5%) 4

Management of Vasospasm

• The vasospasm should be addressed separately from the aneurysm treatment 1
• Medical management with calcium channel blockers is first-line therapy for vasospasm 7
• Endovascular treatment with intraarterial vasodilators may be considered for refractory vasospasm 7
• Stenting specifically for vasospasm should only be considered as a bail-out option for severe refractory cases, not as primary treatment 7

Follow-up Recommendations

• After treatment, early documentation of the degree of aneurysm obliteration is necessary 1
• Regular follow-up imaging is essential to detect recurrence, with frequency determined by the completeness of initial obliteration 1
• Assessment of cognitive outcome in addition to standard measures is reasonable after any aneurysm treatment 1