Abstract
INTRODUCTION: Ruptured anterior communicating artery (ACoA) aneurysms represent a heterogeneous subset of intracranial aneurysms, often with morphological features that influence treatment modality. METHODS: All patients with ruptured ACoA aneurysms enrolled in the Barrow Ruptured Aneurysm Trial (BRAT), a prospective randomized clinical trial, from 2003 to 2007 were included in this subset study. Clinical follow-up of 1- and 3- years was analyzed and patient charts were reviewed for demographic data, aneurysm characteristics, and in-hospital complications. RESULTS: There were 130 patients with a mean age of 53 years in this cohort, of which 52 (40%) were female and 78 (60%) were male. Mean aneurysm size was 5.8 mm, most commonly projecting anteriorly (n = 52). After randomization and crossover, 91 (69.5%) were clipped and 39 (29.8%) were coiled. Twenty-two (16.9%) patients randomized to coiling crossed over to clipping after evaluation; no patients crossed over from clipping to coiling. Aneurysm characteristics deemed unsuitable for coiling included unfavorable dome-to-neck ratio, difficult catheter access, and branch vessel involvement without the ability to protect the parent vessel. Aneurysm size and projection were not significantly associated with actual treatment group, clinical outcome, or retreatment. There was no significant difference in clinical outcome by mRS between the 2 groups at discharge, and 1- and 3- years (P = .37, .45, .95, respectively). Variables associated with poor outcome included history of atherosclerotic disease, diabetes and incidence of stroke during initial hospitalization, whereas there was no significant association seen with retreatment, rebleed, or other hemorrhagic complications. Retreatment was performed in 2 (1.5%) clipped patients and 5 (3.8%) coiled patients. CONCLUSION: Ruptured ACoA aneurysms were safely treated by both treatment modalities in a large-scale randomized clinical trial after select patients were crossed over from the coil to clip group, regardless of aneurysm size and projection. This represents a subset of cerebral aneurysms that seem to demonstrate clinical equipoise for modern treatment paradigms.