Treatment of ICA Junction Anterior Communicating Artery (ACom) Aneurysms
Primary Treatment Recommendation
For ruptured ACom aneurysms amenable to both techniques, endovascular coiling is preferred over surgical clipping to improve 1-year functional outcomes, while for unruptured aneurysms in young, healthy patients with small anterior circulation aneurysms, microsurgical clipping should be the first choice due to superior long-term durability. 1
Treatment Algorithm Based on Rupture Status
For Ruptured ACom Aneurysms
Endovascular coiling is the preferred initial approach when the aneurysm is technically amenable to both coiling and clipping, as it improves 1-year functional outcomes compared to surgical clipping 1
Both endovascular and neurosurgical specialists should evaluate all ruptured aneurysms to determine the optimal treatment approach 1
Treatment should be performed early (within 24-72 hours) to reduce rebleeding risk, which is the primary cause of mortality after initial rupture 1
Technical success rates for endovascular coiling of ACom aneurysms reach 98%, with complete obliteration achieved in 94% of cases 2
For Unruptured ACom Aneurysms
Microsurgical clipping is preferred for young patients (under 60 years) with small anterior circulation aneurysms because surgical clipping provides repair that is at least an order of magnitude more durable than coiling 1, 3
ACom aneurysms carry higher rupture risk than other locations (along with PComA and basilar apex), making treatment strongly indicated even for aneurysms ≥5mm in patients under 60 years 1, 3
The 6-week recuperation period and invasiveness of clipping are acceptable trade-offs in young, healthy patients given the superior long-term durability 1
Specific Technical Considerations
When Coiling is Technically Favorable
Aneurysms with narrow necks and favorable dome-to-neck ratios are ideal for endovascular treatment 1
Stent-assisted coiling can be used for wider-necked aneurysms, requiring dual antiplatelet therapy (aspirin and clopidogrel) to prevent stent thrombosis 4
Very small ACom aneurysms (≤3mm) can be safely coiled, though smaller size may limit endovascular feasibility and require surgical clipping 5
When Clipping is Technically Superior
Wide-necked aneurysms unsuitable for endovascular occlusion require surgical clipping 3
Very large and giant aneurysms with high neck-to-dome ratios generally benefit more from surgical approaches 1
Aneurysms with A1 segment complete configuration more often require surgical clipping, while symmetric A1 configurations favor coiling 5
Critical Management Pitfall: Recurrence Patterns
For recurrent ACom aneurysms after initial endovascular treatment, microsurgical clipping is strongly recommended over repeat coiling. 6
The retreatment rate after initial coiling is 22.4%, with a combined frequency of subsequent retreatment reaching 42.4% in the coiling group versus 0% in the clipping group 6
Microsurgical reconstruction for recurrent aneurysms leads to durable occlusion and avoids multiple future interventions 6
Flow diversion with Pipeline embolization device can be considered for recurrent ACom aneurysms after failed clipping, with 83% complete occlusion rates and no periprocedural complications 7
High-Risk Patient Modifications
Elderly patients (over 60-70 years) or medically ill patients should receive endovascular coiling as the primary approach, even when clipping is technically feasible, due to lower procedural invasiveness 1
Patients with poor Hunt and Hess grades (4/5) can still undergo successful endovascular treatment, with 13.5% of successfully coiled patients presenting in these grades 2
Essential Follow-Up Requirements
Incompletely clipped or coiled aneurysms have increased rebleeding risk and require long-term angiographic follow-up 1
Six-month follow-up angiography should be performed, with significant recanalization occurring in approximately 3% of coiled ACom aneurysms 2
Complete obliteration of the aneurysm should be the goal whenever possible to minimize long-term rupture risk 1