Anterior Communicating Artery Aneurysm Risk Factors

Anterior Communicating Artery Aneurysm Risk Factors

Age, hypertension, heart disease, diabetes mellitus, cerebral atherosclerosis, aneurysms located at the internal carotid artery (ICA) and aneurysm neck width (N) correlated negatively with rupture risk. Aneurysms located at the anterior communicating artery, bifurcation, irregularity, with a daughter sac, aneurysm height, maximum size, aspect ratio (AR), height-to-width ratio and bottleneck factor were significantly and positively correlated with rupture risk 1).

The anterior communicating artery (AcomA) junction is the most common location for cerebral aneurysms. This might because of increased vascular wall shear stress due to the complex structure of the junction. The aim of a study of İdil Soylu et al. was to investigate the effect of morphological parameters in the development of anterior Communicating Artery Aneurysms. This retrospective study was approved by the institutional ethics committee. A retrospective analysis of the hospital database was performed to identify patients with AcomA aneurysms. Patients with normal computed tomography angiography (CTA) examinations were enrolled in the study as the control group. The control group was similar to the patient group in gender and age. Morphological parameters (vessel diameters, vessel diameter ratios, and vessel angles) on the same side (ipsilateral) and on the opposite side (contralateral) of the patients with aneurysm, and morphological parameters of the control group were compared. A total of 171 subjects were involved in the study (86 patients with aneurysms and 85 patients in the control group). Multivariate regression analysis revealed that the ipsilateral A1-A2 angle (OR: 0.932; 95% CI: 0.903-0.961; p < 0.001), the ipsilateral A1/A2 vessel diameter ratio (OR: 27.725; 95% CI: 1.715-448.139; p = 0.019), and the contralateral internal carotid artery (ICA)/A1 ratio (OR: 11.817; 95% CI: 2.617-53.355; p = 0.001) were significant morphological predictors for developing an aneurysm. An increased contralateral ICA/A1 ratio, an increased ipsilateral A1/A2 vessel diameter ratio, and a narrow bifurcation angle are significant predictors for developing an aneurysm. Therefore, in patients with clinical risk factors these parameters may be interpreted as additional morphological risk factors for developing an aneurysm 2).

An asymmetry of the A1 segment of the anterior cerebral artery is an assumed risk factor for the development of anterior communicating artery aneurysms (ACoAAs).

In clinic, it’s very common to find out the unequal development of section A1 of anteromedial brain artery. The resulting hemodynamic changes are considered to be one of the main reasons for the formation of anterior communicating artery aneurysms 3).

An asymmetry of the A1 segment of the anterior cerebral artery (A1SA) was identified on digital subtraction angiography studies from 127 patients (21.4%) and was strongly associated with ACoAA (p < 0.0001, OR 13.7). An A1SA independently correlated with the occurrence of ACA infarction in patients with ACoAA (p = 0.047) and in those without an ACoAA (p = 0.015). Among patients undergoing ACoAA coiling, A1SA was independently associated with the severity of ACA infarction (p = 0.023) and unfavorable functional outcome (p = 0.045, OR = 2.4).

An A1SA is a common anatomical variation in SAH patients and is strongly associated with ACoAA. Moreover, the presence of A1SA independently increases the likelihood of ACA infarction. In SAH patients undergoing ACoAA coiling, A1SA carries the risk for severe ACA infarction and thus an unfavorable outcome. Clinical trial registration no.: DRKS00005486 ( 4).

Findings in a study of Matsukawa et al. demonstrated that the anterior projection of an ACoA aneurysm may be related to rupturing. The authors would perhaps recommend treatment to patients with unruptured ACoA aneurysms that have an anterior dome projection, a bleb(s), and a size ≥ 5 mm 5)



Wang GX, Zhang D, Wang ZP, Yang LQ, Yang H, Li W. Risk factors for ruptured intracranial aneurysms. Indian J Med Res. 2018 Jan;147(1):51-57. doi: 10.4103/ijmr.IJMR_1665_15. PubMed PMID: 29749361; PubMed Central PMCID: PMC5967217.

İdil Soylu A, Ozturk M, Akan H. Can vessel diameters, diameter ratios, and vessel angles predict the development of anterior communicating artery aneurysms: A morphological analysis. J Clin Neurosci. 2019 Jul 26. pii: S0967-5868(19)30755-6. doi: 10.1016/j.jocn.2019.07.024. [Epub ahead of print] PubMed PMID: 31358430.

Okamoto S, Itoh A. Craniotomy side for neck clipping of the anterior communicating aneurysm via the pterional approach. No Shinkei Geka. 2002;30:285–291.

Jabbarli R, Reinhard M, Roelz R, Kaier K, Weyerbrock A, Taschner C, Scheiwe C, Shah M. Clinical relevance of anterior cerebral artery asymmetry in aneurysmal subarachnoid hemorrhage. J Neurosurg. 2017 Nov;127(5):1070-1076. doi: 10.3171/2016.9.JNS161706. Epub 2016 Dec 23. PubMed PMID: 28009232.

Matsukawa H, Uemura A, Fujii M, Kamo M, Takahashi O, Sumiyoshi S. Morphological and clinical risk factors for the rupture of anterior communicating artery aneurysms. J Neurosurg. 2013 May;118(5):978-83. doi: 10.3171/2012.11.JNS121210. Epub 2012 Dec 14. PubMed PMID: 23240701.

p64 Flow Modulation Device

p64 Flow Modulation Device

(Phenox, Bochum, Germany).

The p64 Flow Modulation Device is a flow diverter. It allows complete deployment and full recoverability. This provides added safety and security.

• Complete deployment and recoverability ensures optimal placement

• Greater neck coverage due to the 64 Nitinol wire braid maximizes hemodynamic flow effect in the aneurysm

• Visualization is achieved by 2 helical strands along entire length of the implant and eight proximal markers

• p64 is mechanically detached once optimally placed

• Implanted via a 0.027“ ID microcatheter

The p64 is a flow modulation device designed to be used in endovascular treatment of intracranial aneurysms. There is limited data on the long-term effectiveness of the device. A study of Sirakov et al. sought to determine the safety and long-term efficacy of this device.

A retrospective review of aprospectively maintained database was performed to identify all patients treated with a p64 between March 2015 and November 2018 at University Hospital St. Ivan Rilski. Anatomical features, intraprocedural complications, clinical, and angiographic outcomes were also taken into account and reviewed.

A total of 72 patients with 72 aneurysms who met the inclusion criteria were identified. Device placement was successful in all patients. Follow-up angiographic imaging at 6 months showed complete occlusion (O’Kelly-Marotta grading scale [OKM] D) in 55 (76.3%) patients, subtotal aneurysmal filling (OKM B) in 10 (13.8%) patients, and neck remnant (OKM C) in 7 (9.7%) patients. Catheter angiography at 12 months was available for 70 patients (97.2%) and of these patients 91.4% of the aneurysms were completely occluded (OKM D) (64/72). Delayed angiography at 24 months was available for 68 patients (94.4%) and of these 98.5% (67/68) had completely occluded aneurysms. A 36-month angiography was available for 61 patients (84.4%) by which point all aneurysms had been completely occluded (100%). Permanent morbidity due to delayed aneurysmal rupture occurred in one patient (1.38%). The mortality rate was 0%. Self-limiting mild intimal hyperplasia was seen in 2 patients (2.72%).

Treatment of intracranial aneurysms with a p64 flow modulation device is safe and effective with a high success rate and only infrequent complication 1).

Girdhar et al., reported the thrombogenic potential of the following flow diversion devices measured experimentally in a novel human blood in-vitro pulsatile flow loop model: Pipeline™ Flex Embolization Device (Pipeline), Pipeline™ Flex Embolization Device with Shield Technology™ (Pipeline Shield), Derivo Embolization Device (Derivo), and P64 Flow Modulation Device (P64). Thrombin generation (Mean ± SD; μg/mL) was measured as: Derivo (28 ± 11), P64 (21 ± 4.5), Pipeline (21 ± 6.2), Pipeline Shield (0.6 ± 0.1) and Negative Control (1.5 ± 1.1). Platelet activation (IU/μL) was measured as: Derivo (4.9 ± 0.7), P64 (5.2 ± 0.7), Pipeline (5.5 ± 0.4), Pipeline Shield (0.3 ± 0.1), and Negative Control (0.9 ± 0.7). They found that Pipeline Shield had significantly lower platelet activation and thrombin generation than the other devices tested (p < .05) and this was comparable to the Negative Control (no device, p > .05). High resolution scanning electron microscopy performed on the intraluminal and cross-sectional surfaces of each device showed the lowest accumulation of platelets and fibrin on Pipeline Shield relative to Derivo, P64, and Pipeline. Derivo and P64 also had higher thrombus accumulation at the flared ends. Pipeline device with Phosphorylcholine surface treatment (Pipeline Shield) could mitigate device material related thromboembolic complications 2).

In preliminary in vivo experiments, antithrombogenic hydrophilic coating (HPC) p64 FDSs appeared to be biocompatible, without acute inflammation 3).

Treatment with p64 is associated with an overall rate of 8.5% moderate in stent stenosis (ISS) (50-75%) and 2.7% severe ISS (>75%), which is comparable with the rate of ISS reported in the literature for other flow diverting stents. There is a tendency for ISS to spontaneously improve over time 4)



Sirakov S, Sirakov A, Bhogal P, Penkov M, Minkin K, Ninov K, Hristov H, Karakostov V, Raychev R. The p64 Flow Diverter-Mid-term and Long-term Results from a Single Center. Clin Neuroradiol. 2019 Aug 9. doi: 10.1007/s00062-019-00823-y. [Epub ahead of print] PubMed PMID: 31399749.

Girdhar G, Ubl S, Jahanbekam R, Thinamany S, Belu A, Wainwright J, Wolf MF. Thrombogenicity assessment of Pipeline, Pipeline Shield, Derivo and P64 flow diverters in an in vitro pulsatile flow human blood loop model. eNeurologicalSci. 2019 Jan 8;14:77-84. doi: 10.1016/j.ensci.2019.01.004. eCollection 2019 Mar. PubMed PMID: 30723811; PubMed Central PMCID: PMC6350389.

Martínez Moreno R, Bhogal P, Lenz-Habijan T, Bannewitz C, Siddiqui A, Lylyk P, Hannes R, Monstadt H, Henkes H. In vivo canine study of three different coatings applied to p64 flow-diverter stents: initial biocompatibility study. Eur Radiol Exp. 2019 Jan 22;3(1):3. doi: 10.1186/s41747-018-0084-z. PubMed PMID: 30671686; PubMed Central PMCID: PMC6342750.

Aguilar Pérez M, Bhogal P, Henkes E, Ganslandt O, Bäzner H, Henkes H. In-stent Stenosis after p64 Flow Diverter Treatment. Clin Neuroradiol. 2018 Dec;28(4):563-568. doi: 10.1007/s00062-017-0591-y. Epub 2017 May 9. PubMed PMID: 28488025; PubMed Central PMCID: PMC6245240.
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