From the Guidelines
An ACom aneurysm rupture is a medical emergency requiring immediate neurosurgical intervention, with treatment options including surgical clipping or endovascular coiling, and the choice depending on aneurysm characteristics and patient factors, as recommended by the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1. Patients with ACom aneurysm rupture should be transported to the nearest comprehensive stroke center for urgent evaluation and treatment. Initial management includes:
- Stabilizing vital signs
- Securing the airway if needed
- Maintaining systolic blood pressure between 120-160 mmHg to balance the risks of rebleeding and cerebral ischemia Treatment options include:
- Surgical clipping
- Endovascular coiling The choice of treatment modality is highly nuanced and should be determined by a multidisciplinary team, including specialists with endovascular and surgical expertise, as recommended by the 2023 guideline 1. The goal of initial treatment is complete obliteration of the ruptured aneurysm, whenever feasible, to reduce the risk of rebleeding and improve outcomes, as supported by the evidence 1. Additional measures include:
- Strict blood pressure control
- Seizure prophylaxis with levetiracetam 500mg twice daily
- Pain management
- Maintaining euvolemia Close neurological monitoring is essential to detect deterioration. ACom aneurysm ruptures cause subarachnoid hemorrhage with blood entering the cerebrospinal fluid spaces, triggering inflammation and potentially causing hydrocephalus, vasospasm, and delayed cerebral ischemia. Mortality rates are significant (30-50%), and survivors often face cognitive and memory deficits due to the aneurysm's location near critical brain structures.
From the Research
Acom Aneurysm Rupture
- Aneurysms of the anterior communicating (ACOM) artery are the most frequently occurring type of ruptured intracranial aneurysms 2.
- The management of ACOM artery aneurysms is challenging due to their deep location and complex anatomy, requiring tailored treatment approaches 2.
- Microsurgical clipping is an important facet of managing ACOM artery aneurysms, especially for those that cannot be coiled 2.
Treatment Options
- Clipping and coiling are two common treatment modalities for ruptured ACOM aneurysms, with no significant difference in clinical outcomes between the two 3.
- Endovascular treatment, including coiling and angioplasty, can be effective in managing ruptured ACOM aneurysms, especially in cases with significant vasospasm 4.
- The choice of treatment modality depends on various factors, including aneurysm morphology, location, and patient demographics 3, 5.
Complications and Outcomes
- Vasospasm is a major cause of morbidity and mortality in patients with ruptured aneurysms, and aggressive endovascular treatment can be effective in reducing its severity 4.
- The risk of recurrence is higher in coiled aneurysms compared to clipped aneurysms, although the risk of rebleed is not statistically significant 5.
- Clinical outcomes, including functional outcome and length of stay, are not significantly different between clipped and coiled aneurysms 3, 5.
Management Strategies
- A multidisciplinary team approach is essential in making treatment decisions for patients with ruptured ACOM aneurysms 3, 5.
- Treatment decisions should be tailored to individual patient needs, taking into account aneurysm characteristics, patient demographics, and other factors 2, 3.
- Continuous nimodipine drip and aggressive angioplasty can be effective in managing vasospasm and improving outcomes in patients with ruptured ACOM aneurysms 6, 4.