J Korean Neurosurg Soc.  2013 Aug;54(2):86-92. 10.3340/jkns.2013.54.2.86.

Anterior Choroidal Artery Aneurysm Surgery: Ischemic Complications and Clinical Outcomes Revisited

• Lee YS
• Park J

• KMID: 1814243
• DOI: http://doi.org/10.3340/jkns.2013.54.2.86

Abstract

OBJECTIVE
Surgical results for anterior choroidal artery (AChA) aneurysms have previously been reported as unsatisfactory due to inadvertent occlusion of the AChA, while the low incidence of AChA aneurysms hampers the accumulation of surgical experience. The authors reviewed their related surgical experience to document the ischemic complications and surgical outcomes.
METHODS
Identification of the AChA at its origin by rigorous visual scrutiny, careful microdissection, and meticulous clip placement to avoid the AChA origin are all crucial surgical maneuvers. A retrospective review of a surgical series of 62 consecutive cases of an AChA aneurysm between 2004 and 2012 was performed.
RESULTS
All patients, except for five (8.1%) with a small residual neck, showed complete aneurysm obliteration in postoperative angiographic evaluations. There was no incidence of procedure-related permanent AChA syndrome or oculomotor nerve palsy, while three (4.8%) patients suffered from transient AChA syndrome. The clinical outcomes [the 3-month modified Rankin Scale (mRS)] of the patients were related to their preoperative World Federation of Neurologic Surgeons (WFNS) grade. As regards the 3-month mRS, significant differences were found between patients with an unruptured aneurysm (WFNS grade 0; n=20), good-grade subarachnoid hemorrhage (WFNS grade 1-3; n=30), and poor-grade subarachnoid hemorrhage (WFNS grade 4-5; n=4).
CONCLUSION
In surgical treatment of AChA aneurysms, a risk of AChA insufficiency can be minimized by taking every precaution to preserve the AChA patency and intraoperative monitoring. In addition, the surgical outcome is primarily determined by the preoperative clinical state.

Keyword

Anterior choroidal artery; Anterior choroidal artery infarction; Intracranial aneurysm; Surgical procedures; Treatment outcome

MeSH Terms

Adenosine
Aneurysm
Arteries
Cerebral Infarction
Choroid
Humans
Incidence
Intracranial Aneurysm
Microdissection
Monitoring, Intraoperative
Neck
Oculomotor Nerve Diseases
Retrospective Studies
Subarachnoid Hemorrhage
Treatment Outcome
Adenosine

Figure

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  Fig. 1 Illustration showing clip placement when an AChA arises inferior to aneurysm. The proximal blade of the clip is positioned a small distance away from the origin of the AChA so as not to constrict the AChA, while the distal blade is positioned adjacent to the wall of the ICA. Note the distance between the AChA origin and the clip blades (arrow). AChA: anterior choroidal artery, ICA: internal carotid artery.

• 

  Fig. 2 Illustration showing clip placement when AChA arises posterior to aneurysm base. A straight clip is applied across the base of the aneurysm perpendicular to the axis of the ICA, while tilting laterally away from the origin of the AChA. Note the distance between the AChA origin and the clip blades (red arrow). AChA: anterior choroidal artery, ICA: internal carotid artery.

• 

  Fig. 3 Complicated case with postoperative hemiplegia. A: Intraoperative photograph showing AChA aneurysm with daughter sac. B: Intraoperative photograph showing AChA origin posterior to aneurysm base, reveals when compressing the aneurysm with blunt dissecter. C: Intraoperative photograph showing initial clip placement using side-curved clip. D: Illustration showing initial clip placement and resultant constriction of AChA origin. E: Intraoperative photograph showing changed clip placement using straight clip tilted laterally in immediate reoperation. F: Illustration showing changed clip placement to obtain luminal patency of AChA. AChA: anterior choroidal artery, ICA: internal carotid artery.

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  Fig. 4 Bar graph showing significant influence of WFNS grade on 3-month mRS in patients with AChA aneurysm. AChA: anterior choroidal artery, ICA: internal carotid artery, mRS: modified Rankin Scale, WFNS: World Federation of Neurologic Surgeons.

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  Fig. 5 Clinical characteristics and imaging results for 4 patients who presented with contralateral hemiparesis after AChA aneurysm rupture on admission. AChA: anterior choroidal artery, GCS: Glasgow Coma Scale, mRS: modified Rankin Scale, WFNS: World Federation of Neurologic Surgeons.

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