Impact of Very Small Aneurysm Size and Anterior Communicating Segment Location on Outcome after Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Very small anterior communicating artery aneurysms (vsACoA) of <5 mm in size are detected in a considerable number of patients with aneurysmal subarachnoid hemorrhage (aSAH). Single-center studies report that vsACoA harbor particular risks when treated. OBJECTIVE: To assess the clinical and radiological outcome(s) of patients with aSAH diagnosed with vsACoA after aneurysm treatment and at discharge. METHODS: Information on n = 1868 patients was collected in the Swiss Subarachnoid Hemorrhage Outcome Study registry between 2009 and 2014. The presence of a new focal neurological deficit at discharge, functional status (modified Rankin scale), mortality rates, and procedural complications (in-hospital rebleeding and presence of a new stroke on computed tomography) was assessed for vsACoA and compared with the results observed for aneurysms in other locations and with diameters of 5 to 25 mm. RESULTS: This study analyzed n = 1258 patients with aSAH, n = 439 of which had a documented ruptured ACoA. ACoA location was found in 38% (n = 144/384) of all very small ruptured aneurysms. A higher in-hospital bleeding rate was found in vsACoA compared with non-ACoA locations (2.8 vs 2.1%), especially when endovascularly treated (2.1% vs 0.5%). In multivariate analysis, aneurysm size of 5 to 25 mm, and not ACoA location, was an independent risk factor for a new focal neurological deficit and a higher modified Rankin scale at discharge. Neither very small aneurysm size nor ACoA location was associated with higher mortality rates at discharge or the occurrence of a peri-interventional stroke. CONCLUSION: Very small ruptured ACoA have a higher in-hospital rebleeding rate but are not associated with worse morbidity or mortality.

Standard of practice: endovascular treatment of intracranial atherosclerosis.

BACKGROUND: Symptomatic intracranial atherosclerotic disease (ICAD) worldwide represents one of the most prevalent causes of stroke. When severe, studies show that it has a very high risk for recurrent stroke, highlighting the need for effective preventative strategies. The mainstay of treatment has been medical therapy and is of critical importance in all patients with this disease. Endovascular therapy is also a possible therapeutic option but much remains to be defined in terms of best techniques and patient selection. This guideline will serve as recommendations for diagnosis and endovascular treatment of patients with ICAD. METHODS: A literature review was performed to extract published literature regarding ICAD, published from 2000 to 2011. Evidence was evaluated and classified according to American Heart Association (AHA)/American Stroke Association standard. Recommendations are made based on available evidence assessed by the Standards Committee of the Society of NeuroInterventional Surgery. The assessment was based on guidelines for evidence based medicine proposed by the American Academy of Neurology (AAN), the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM). RESULTS: 59 publications were identified. The SAMMPRIS study is the only prospective, randomized, controlled trial available and is given an AHA level B designation, AAN class II and CEBM level 1b. The Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial arteries (SSYLVIA) trial was a prospective, non-randomized study with the outcome assessment made by a non-operator study neurologist, allowing an AHA level B, AAN class III and CEBM level 2. The remaining studies were uncontrolled or did not have objective outcome measurement, and are thus classified as AHA level C, AAN class IV and CEBM level 4. CONCLUSION: Medical management with combination aspirin and clopidogrel for 3 months and aggressive risk factor modification is the firstline therapy for patients with symptomatic ICAD. Endovascular angioplasty with or without stenting is a possible therapeutic option for selected patients with symptomatic ICAD. Further studies are necessary to define appropriate patient selection and the best therapeutic approach for various subsets of patients.