Anterior cervical disc arthroplasty versus anterior cervical discectomy and fusion

While anterior cervical discectomy and fusion (ACDF) has been the standard of care for 2-level disease, a randomized clinical trial (RCT) suggested similar outcomes.

There are also critical debates regarding the long-term effects of heterotopic ossification (HO) and the prevalence of adjacent-level degeneration.


One hundred-nine patients with one level cervical disc herniation, were randomized to one of the following treatments: Anterior cervical disc arthroplasty (ACDA), Anterior cervical discectomy and fusion (ACDF) with intervertebral cage, Anterior cervical discectomy (ACD) without fusion. Clinical and radiological outcome was measured by NDI, Visual Analogue Scale (VAS) neck pain, VAS arm pain, SF-36, EQ-5D, patients’ self-reported perceived recovery, radiographic cervical curvature, and adjacent segment degeneration (ASD) parameters at baseline and until two years after surgery. BBraun Medical paid €298.837 to cover the costs for research nurses.

The NDI declined from 41 to 47 points at baseline to 19±15 in the ACD group, 19± 18 in the ACDF group, and 20±22 in the ACDA group after surgery (p=0.929). VAS arm and neck pain declined to half its baseline value and decreased below the critical value of 40 mm. Quality of life, measured by the EQ-5D, increased in all three groups. ASD parameters were comparable in all three groups as well. No statistical differences were demonstrated between the treatment groups.

The hypothesis that ACDA would lead to superior clinical outcome in comparison to ACDF or ACD could not be confirmed during a two-year follow-up time period. Single level ACD without implanting an intervertebral device may be a reasonable alternative to ACDF or ACDA 1).


Findlay et al., from London and Edinburgh, researched for cervical total disc replacement versus anterior cervical discectomy and fusion.

Databases including Medline, Embase, and Scopus were searched. Inclusion criteria involved prospective randomized control trials (RCTs) reporting the surgical treatment of patients with symptomatic degenerative cervical disc disease. Two independent investigators extracted the data. The strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. The primary outcome measures were overall and neurological success, and these were included in the meta-analysis. Standardized patient-reported outcomes, including the incidence of further surgery and adjacent segment disease, were summarized and discussed.

A total of 22 papers published from 14 randomized control trials (RCTs) were included, representing 3160 patients with follow-up of up to ten years. Meta-analysis indicated that TDR is superior to ACDF at two years and between four and seven years. In the short-term, patients who underwent TDR had better patient-reported outcomes than those who underwent ACDF, but at two years this was typically not significant. Results between four and seven years showed significant differences in Neck Disability Index (NDI), 36-Item Short-Form Health Survey (SF-36) physical component scores, dysphagia, and satisfaction, all favouring TDR. Most trials found significantly less adjacent segment disease after TDR at both two years (short-term) and between four and seven years (medium- to long-term).

TDR is as effective as ACDF and superior for some outcomes. Disc replacement reduces the risk of adjacent segment disease. Continued uncertainty remains about degeneration of the prosthesis. Long-term surveillance of patients who undergo TDR may allow its routine use 2).


Cervical total disc replacement (TDR) has been shown in a number of prospective clinical studies to be a viable treatment alternative to anterior cervical discectomy and fusion (ACDF) for symptomatic cervical degenerative disc disease. In addition to preserving motion, evidence suggests that cervical TDR may result in a lower incidence of subsequent surgical intervention than treatment with fusion.

One reason for this trend is the observation that in clinical studies, patients with a history of cervical arthrodesis seem to have a higher incidence of adjacent segment degeneration 3) 4) 5).

Furthermore, in biomechanical investigations, most authors have reported an increase in the segmental range of motion (ROM) and the intradiscal pressure (IDP) in the levels proximal and distal to a simulated mono- or bisegmental arthrodesis 6) 7) 8) 9) 10) 11) 12) 13) 14) 15).

References

1)

Vleggeert-Lankamp CLA, Janssen TMH, van Zwet E, Goedmakers CMW, Bosscher L, Peul W, Arts MP. The NECK trial: Effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blinded randomised controlled trial. Spine J. 2018 Dec 21. pii: S1529-9430(18)31322-6. doi: 10.1016/j.spinee.2018.12.013. [Epub ahead of print] PubMed PMID: 30583108.
2)

Findlay C, Ayis S, Demetriades AK. Total disc replacement versus anterior cervical discectomy and fusion. Bone Joint J. 2018 Aug;100-B(8):991-1001. doi: 10.1302/0301-620X.100B8.BJJ-2018-0120.R1. PubMed PMID: 30062947.
3)

Goffin J, Geusens E, Vantomme N, Quintens E, Waerzeggers Y, Depreitere B, et al. Long-term follow-up after interbody fusion of the cervical spine. J Spinal Disord Tech. 2004;17:79–85. doi: 10.1097/00024720-200404000-00001.
4)

Gore DR, Sepic SB. Anterior discectomy and fusion for painful cervical disc disease: a report of 50 patients with an average follow-up of 21 years. Spine. 1998;23:2047–2051. doi: 10.1097/00007632-199810010-00002.
5)

Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman H. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg. 1999;81-A:519–528.
6)

Chang U-K, Kim DH, Lee MC, Willenberg R, Kim S-H, Lim J. Changes in adjacent-level disc pressure and facet joint force after cervical arthroplasty compared with cervical discectomy and fusion. J Neurosurg Spine. 2007;7:33–39. doi: 10.3171/SPI-07/07/033.
7)

Chang U-K, Kim DH, Lee MC, Willenberg R, Kim S-H, Lim J. Range of motion change after cervical arthroplasty with ProDisc-C and Prestige artificial discs compared with anterior cervical discectomy and fusion. J Neurosurg Spine. 2007;7:40–46. doi: 10.3171/SPI-07/07/040.
8)

DiAngelo DJ, Foley KT, Morrow BR, Schwab JS, Song J, German JW, et al. In vitro biomechanics of cervical disc arthroplasty with the ProDisc-C total disc implant. Neurosurg Focus. 2004;17(E7):44–54. doi: 10.3171/foc.2004.17.3.7.
9)

DiAngelo DJ, Robertson JT, Metcalf NH, McVay BJ, Davis RC. Biomechanical testing of an artificial cervical joint and an anterior plate. J Spinal Disord Tech. 2003;16:314–323. doi: 10.1097/00024720-200308000-00002.
10)

Dmitriev AE, Cunningham BW, Hu N, Sell G, Vigna F, McAfee PC. Adjacent level intradiscal pressure and segmental kinematics following a cervical total disc arthroplasty. An in vitro human cadaveric model. Spine. 2005;30:1165–1172. doi: 10.1097/01.brs.0000162441.23824.95.
11)

Eck JC, Humphreys SC, Lim T-H, Jeong ST, Kim JG, Hodges SD, et al. Biomechanical study on the effect of cervical spine fusion on adjacent-level intradiscal pressure and segmental motion. Spine. 2002;27:2431–2434. doi: 10.1097/00007632-200211150-00003.
12)

Fuller DA, Kirkpatrick JS, Emery SE. A kinematic study of the cervical spine before and after segmental arthrodesis. Spine. 1998;23:1649–1656. doi: 10.1097/00007632-199808010-00006.
13)

Park D-H, Ramakrishnan P, Cho T-H, Lorenz E, Eck JC, Humphreys SC, et al. Effect of lower two-level anterior cervical fusion on the superior adjacent level. J Neurosurg Spine. 2007;7:336–340. doi: 10.3171/SPI-07/09/336.
14)

Pospiech J, Stolke D, Wilke HJ, Claes LE. Intradiscal pressure recordings in the cervical spine. Neurosurgery. 1999;44:379–384. doi: 10.1097/00006123-199902000-00078.
15)

Ragab AA, Escarcega AJ, Zdeblick TA. A quantitative analysis of strain at adjacent segments after segmental immobilization of the cervical spine. J Spinal Disord Tech. 2006;19:407–410. doi: 10.1097/00024720-200608000-00006.

Anterior temporal lobectomy (ATL)

Anterior temporal lobectomy for mesial temporal sclerosis is a very effective measure to control seizures, and the probability of being seizure-free is approximately 70-90%. However, 30% of patients still experience seizures after surgery.

In neurosurgery there are several situations that require transgression of the temporal cortex. For example, a subset of patients with temporal lobe epilepsy require surgical resection (most typically, en-bloc anterior temporal lobectomy). This procedure is the gold standard to alleviate seizures but is associated with chronic cognitive deficits. In recent years there have been multiple attempts to find the optimum balance between minimising the size of resection in order to preserve cognitive function, while still ensuring seizure freedom. Some attempts involve reducing the distance that the resection stretches back from the temporal pole, whilst others try to preserve one or more of the temporal gyri. More recent advanced surgical techniques (selective amygdalohippocampectomy) try to remove the least amount of tissue by going under (sub-temporal), over (trans-Sylvian) or through the temporal lobe (middle-temporal), which have been related to better cognitive outcomes. Previous comparisons of these surgical techniques focus on comparing seizure freedom or behaviour post-surgery, however there have been no systematic studies showing the effect of surgery on white matter connectivity. The main aim of this study, therefore, was to perform systematic ‘pseudo-neurosurgery’ based on existing resection methods on healthy neuroimaging data and measuring the effect on long-range connectivity. We use anatomical connectivity maps (ACM) to determine long-range disconnection, which is complementary to existing measures of local integrity such as fractional anisotropy or mean diffusivity. ACMs were generated for each diffusion scan in order to compare whole-brain connectivity with an ‘ideal resection’, nine anterior temporal lobectomy and three selective approaches. For en-bloc resections, as distance from the temporal pole increased, reduction in connectivity was evident within the arcuate fasciculusinferior longitudinal fasciculusinferior frontooccipital fascicle, and the uncinate fasciculus. Increasing the height of resections dorsally reduced connectivity within the uncinate fasciculus. Sub-temporal amygdalohippocampectomy resections were associated with connectivity patterns most similar to the ‘ideal’ baseline resection, compared to trans-Sylvian and middle-temporal approaches. In conclusion, we showed the utility of ACM in assessing long-range disconnections/disruptions during temporal lobe resections, where we identified the subtemporal resection as the least disruptive to long-range connectivity which may explain its better cognitive outcome. These results have a direct impact on understanding the amount and/or type of cognitive deficit post-surgery, which may not be obtainable using local measures of white matter integrity 1).

Anterior temporal lobectomy (ATL) with amygdalohippocampectomy (ATLAH) has been shown to be more efficacious than continued medical therapy in a randomized, controlled trial 2).

Minimally invasive approaches to treating MTLE might achieve seizure freedom while minimizing adverse effects.

Anterior temporal lobectomy as described by Penfield and Baldwin 3). is the most established neurosurgical procedure for temporal lobe epilepsy, for those in whom anticonvulsant medications do not control epileptic seizures.

It consists in the complete removal of the anterior portion of the temporal lobe of the brain.

Knowledge of the temporomesial region, including neurovascular structures around the brainstem, is essential to keep this procedure safe and effective 4).

The techniques for removing temporal lobe tissue vary from resection of large amounts of tissue, including lateral temporal cortex along with medial structures, to more restricted anterior temporal lobectomy (ATL) to more restricted removal of only the medial structures (selective amygdalohippocampectomy, SAH).

Limits of resection

The measurements are made along the middle temporal gyrus.

Dominant temporal lobe: Up to 4-5 cm may be removed

Non Dominant: 6- 7 cm.


Nearly all reports of seizure outcome following these procedures indicate that the best outcome group includes patients with MRI evidence of mesial temporal sclerosis (hippocampal atrophy with increased T-2 signal.) The range of seizure-free outcomes for these patients is reported to be between 80 and 90%, which is typically reported as a sub-set of data within a larger surgical series.

Open surgical procedures such as ATL have inherent risks including damage to the brain (either directly or indirectly by injury to important blood vessels), bleeding (which can require re-operation), blood loss (which can require transfusion), and infection. Furthermore, open procedures require several days of care in the hospital including at least one night in an intensive care unit. Although such treatment can be costly, multiple studies have demonstrated that ATL in patients who have failed at least two anticonvulsant drug trials (thereby meeting the criteria for medically intractable temporal lobe epilepsy) has lower mortality, lower morbidity and lower long-term cost in comparison with continued medical therapy without surgical intervention.

The strongest evidence supporting ATL over continued medical therapy for medically refractory temporal lobe epilepsy is a prospective, randomized trial of ATL compared to best medical therapy (anticonvulsants), which convincingly demonstrated that the seizure-free rate after surgery was ~ 60% as compared to only 8% for the medicine only group.

Furthermore, there was no mortality in the surgery group, while there was seizure-related mortality in the medical therapy group. Therefore, ATL is considered the standard of care for patients with medically intractable mesial temporal lobe epilepsy.

Surgical resection is the gold standard treatment for drug-resistant focal epilepsy, including mesial temporal lobe epilepsy (MTLE) and other focal cortical lesions with correlated electrophysiological features. Anterior temporal lobectomy with amygdalohippocampectomy (ATLAH) has been shown to be more efficacious than continued medical therapy in a randomized, controlled trial 5).

The most common surgical procedure for the mesial temporal lobe is the standard anterior temporal resection or what is commonly called the anterior temporal lobectomy. There are, however, a number of other more selective procedures for removal of the mesial temporal lobe structures (amygdala, hippocampus, and parahippocampal gyrus) that spare much of the lateral temporal neocortex. Included in these procedures collectively referred to as selective amygdalohippocampectomy are the transsylvian, subtemporal, and transcortical (trans-middle temporal gyrus) selective amygdalohippocampectomy 6).

The ATL group scored significantly worse for recognition of fear compared with selective amygdalohippocampectomy (SAH) patients. Inversely, after SAH scores for disgust were significantly lower than after ATL, independently of the side of resection. Unilateral temporal damage impairs facial emotion recognition (FER). Different neurosurgical procedures may affect FER differently 7).

Outcome

Functional MRIResting state fMRIdiffusion tensor imaging modalities can be used effectively, in an additive fashion, to predict functional reorganization and cognitive outcome following anterior temporal lobectomy 8).

Complications

Case series

Of 1214 patients evaluated for surgery in the epilepsy Center of Faculdade de Medicina de São Jose do Rio Preto (FAMERP), a tertiary Brazilian epilepsy center, 400 underwent ATL for MTS. Number and type of auras was analyzed and compared with Engel Epilepsy Surgery Outcome Scalefor outcome.

Analyzing the patients by the type of aura, those who had extratemporal auras had worst result in post-surgical in Engel classifcation. While mesial auras apparently is a good prognostic factor. Patients without aura also had worse prognosis. Simple and multiple aura had no difference. In order to identify the most appropriate candidates for ATL, is very important to consider the prognostic factors associated with favorable for counseling patients in daily practice 9).


Boucher et al. compared preoperative vs. postoperative memory performance in 13 patients with selective amygdalohippocampectomy (SAH) with 26 patients who underwent ATL matched on side of surgery, IQ, age at seizure onset, and age at surgery. Memory function was assessed using the Logical Memory subtest from the Wechsler Memory Scales – 3rd edition (LM-WMS), the Rey Auditory Verbal Learning Test (RAVLT), the Digit Span subtest from the Wechsler Adult Intelligence Scale, and the Rey-Osterrieth Complex Figure Test. Repeated measures analyses of variance revealed opposite effects of SAH and ATL on the two verbal learning memory tests. On the immediate recall trial of the LM-WMS, performance deteriorated after ATL in comparison with that after SAH. By contrast, on the delayed recognition trial of the RAVLT, performance deteriorated after SAH compared with that after ATL. However, additional analyses revealed that the latter finding was only observed when surgery was conducted in the right hemisphere. No interaction effects were found on other memory outcomes. The results are congruent with the view that tasks involving rich semantic content and syntactical structure are more sensitive to the effects of lateral temporal cortex resection as compared with mesiotemporal resection. The findings highlight the importance of task selection in the assessment of memory in patients undergoing TLE surgery10).

References

1)

Busby N, Halai AD, Parker GJM, Coope DJ, Lambon Ralph MA. Mapping whole brain connectivity changes: The potential impact of different surgical resection approaches for temporal lobe epilepsy. Cortex. 2018 Nov 17;113:1-14. doi: 10.1016/j.cortex.2018.11.003. [Epub ahead of print] PubMed PMID: 30557759.
2) , 5)

Wiebe S, Blume WT, Girvin JP, Eliasziw M. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001;345(5):311–318.
3)

PENFIELD W, BALDWIN M. Temporal lobe seizures and the technic of subtotal temporal lobectomy. Ann Surg. 1952 Oct;136(4):625-34. PubMed PMID: 12986645; PubMed Central PMCID: PMC1803045.
4)

Schaller K, Cabrilo I. Anterior temporal lobectomy. Acta Neurochir (Wien). 2016 Jan;158(1):161-6. doi: 10.1007/s00701-015-2640-0. Epub 2015 Nov 23. PubMed PMID: 26596998.
6)

Wheatley BM. Selective amygdalohippocampectomy: the trans-middle temporal gyrus approach. Neurosurg Focus. 2008 Sep;25(3):E4. doi: 10.3171/FOC/2008/25/9/E4. Review. PubMed PMID: 18759628.
7)

Wendling AS, Steinhoff BJ, Bodin F, Staack AM, Zentner J, Scholly J, Valenti MP, Schulze-Bonhage A, Hirsch E. Selective amygdalohippocampectomy versus standard temporal lobectomy in patients with mesiotemporal lobe epilepsy and unilateral hippocampal sclerosis: post-operative facial emotion recognition abilities. Epilepsy Res. 2015 Mar;111:26-32. doi: 10.1016/j.eplepsyres.2015.01.002. Epub 2015 Jan 16. PubMed PMID: 25769370.
8)

Osipowicz K, Sperling MR, Sharan AD, Tracy JI. Functional MRI, resting state fMRI, and DTI for predicting verbal fluency outcome following resective surgery for temporal lobe epilepsy. J Neurosurg. 2016 Apr;124(4):929-37. doi: 10.3171/2014.9.JNS131422. Epub 2015 Sep 25. PubMed PMID: 26406797.
9)

da Cruz Adry RAR, Meguins LC, Pereira CU, da Silva Júnior SC, de Araújo Filho GM, Marques LHN. Auras as a prognostic factor in anterior temporal lobe resections for mesial temporal sclerosis. Eur J Neurol. 2018 Jun 28. doi: 10.1111/ene.13740. [Epub ahead of print] PubMed PMID: 29953714.
10)

Boucher O, Dagenais E, Bouthillier A, Nguyen DK, Rouleau I. Different effects of anterior temporal lobectomy and selective amygdalohippocampectomy on verbal memory performance of patients with epilepsy. Epilepsy Behav. 2015 Oct 12;52(Pt A):230-235. doi: 10.1016/j.yebeh.2015.09.012. [Epub ahead of print] PubMed PMID: 26469799.

UpToDate: Cervical total disc replacement versus anterior cervical discectomy and fusion

Cervical total disc replacement versus anterior cervical discectomy and fusion

Findlay et al., from London and Edinburgh, researched for cervical total disc replacement versus anterior cervical discectomy and fusion.

Databases including Medline, Embase, and Scopus were searched. Inclusion criteria involved prospective randomized control trials (RCTs) reporting the surgical treatment of patients with symptomatic degenerative cervical disc disease. Two independent investigators extracted the data. The strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. The primary outcome measures were overall and neurological success, and these were included in the meta-analysis. Standardized patient-reported outcomes, including the incidence of further surgery and adjacent segment disease, were summarized and discussed.

A total of 22 papers published from 14 randomized control trials (RCTs) were included, representing 3160 patients with follow-up of up to ten years. Meta-analysis indicated that TDR is superior to ACDF at two years and between four and seven years. In the short-term, patients who underwent TDR had better patient-reported outcomes than those who underwent ACDF, but at two years this was typically not significant. Results between four and seven years showed significant differences in Neck Disability Index (NDI), 36-Item Short-Form Health Survey (SF-36) physical component scores, dysphagia, and satisfaction, all favouring TDR. Most trials found significantly less adjacent segment disease after TDR at both two years (short-term) and between four and seven years (medium- to long-term).

TDR is as effective as ACDF and superior for some outcomes. Disc replacement reduces the risk of adjacent segment disease. Continued uncertainty remains about degeneration of the prosthesis. Long-term surveillance of patients who undergo TDR may allow its routine use 1).


Cervical total disc replacement (TDR) has been shown in a number of prospective clinical studies to be a viable treatment alternative to anterior cervical discectomy and fusion (ACDF) for symptomatic cervical degenerative disc disease. In addition to preserving motion, evidence suggests that cervical TDR may result in a lower incidence of subsequent surgical intervention than treatment with fusion.

One reason for this trend is the observation that in clinical studies, patients with a history of cervical arthrodesis seem to have a higher incidence of adjacent segment degeneration 2) 3) 4).

Furthermore, in biomechanical investigations, most authors have reported an increase in the segmental range of motion (ROM) and the intradiscal pressure (IDP) in the levels proximal and distal to a simulated mono- or bisegmental arthrodesis 5) 6) 7) 8) 9) 10) 11) 12) 13) 14).

While anterior cervical discectomy and fusion (ACDF) has been the standard of care for 2-level disease, a randomized clinical trial (RCT) suggested similar outcomes.

There are also critical debates regarding the long-term effects of heterotopic ossification (HO) and the prevalence of adjacent-level degeneration.

1)

Findlay C, Ayis S, Demetriades AK. Total disc replacement versus anterior cervical discectomy and fusion. Bone Joint J. 2018 Aug;100-B(8):991-1001. doi: 10.1302/0301-620X.100B8.BJJ-2018-0120.R1. PubMed PMID: 30062947.
2)

Goffin J, Geusens E, Vantomme N, Quintens E, Waerzeggers Y, Depreitere B, et al. Long-term follow-up after interbody fusion of the cervical spine. J Spinal Disord Tech. 2004;17:79–85. doi: 10.1097/00024720-200404000-00001.
3)

Gore DR, Sepic SB. Anterior discectomy and fusion for painful cervical disc disease: a report of 50 patients with an average follow-up of 21 years. Spine. 1998;23:2047–2051. doi: 10.1097/00007632-199810010-00002.
4)

Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman H. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg. 1999;81-A:519–528.
5)

Chang U-K, Kim DH, Lee MC, Willenberg R, Kim S-H, Lim J. Changes in adjacent-level disc pressure and facet joint force after cervical arthroplasty compared with cervical discectomy and fusion. J Neurosurg Spine. 2007;7:33–39. doi: 10.3171/SPI-07/07/033.
6)

Chang U-K, Kim DH, Lee MC, Willenberg R, Kim S-H, Lim J. Range of motion change after cervical arthroplasty with ProDisc-C and Prestige artificial discs compared with anterior cervical discectomy and fusion. J Neurosurg Spine. 2007;7:40–46. doi: 10.3171/SPI-07/07/040.
7)

DiAngelo DJ, Foley KT, Morrow BR, Schwab JS, Song J, German JW, et al. In vitro biomechanics of cervical disc arthroplasty with the ProDisc-C total disc implant. Neurosurg Focus. 2004;17(E7):44–54. doi: 10.3171/foc.2004.17.3.7.
8)

DiAngelo DJ, Robertson JT, Metcalf NH, McVay BJ, Davis RC. Biomechanical testing of an artificial cervical joint and an anterior plate. J Spinal Disord Tech. 2003;16:314–323. doi: 10.1097/00024720-200308000-00002.
9)

Dmitriev AE, Cunningham BW, Hu N, Sell G, Vigna F, McAfee PC. Adjacent level intradiscal pressure and segmental kinematics following a cervical total disc arthroplasty. An in vitro human cadaveric model. Spine. 2005;30:1165–1172. doi: 10.1097/01.brs.0000162441.23824.95.
10)

Eck JC, Humphreys SC, Lim T-H, Jeong ST, Kim JG, Hodges SD, et al. Biomechanical study on the effect of cervical spine fusion on adjacent-level intradiscal pressure and segmental motion. Spine. 2002;27:2431–2434. doi: 10.1097/00007632-200211150-00003.
11)

Fuller DA, Kirkpatrick JS, Emery SE. A kinematic study of the cervical spine before and after segmental arthrodesis. Spine. 1998;23:1649–1656. doi: 10.1097/00007632-199808010-00006.
12)

Park D-H, Ramakrishnan P, Cho T-H, Lorenz E, Eck JC, Humphreys SC, et al. Effect of lower two-level anterior cervical fusion on the superior adjacent level. J Neurosurg Spine. 2007;7:336–340. doi: 10.3171/SPI-07/09/336.
13)

Pospiech J, Stolke D, Wilke HJ, Claes LE. Intradiscal pressure recordings in the cervical spine. Neurosurgery. 1999;44:379–384. doi: 10.1097/00006123-199902000-00078.
14)

Ragab AA, Escarcega AJ, Zdeblick TA. A quantitative analysis of strain at adjacent segments after segmental immobilization of the cervical spine. J Spinal Disord Tech. 2006;19:407–410. doi: 10.1097/00024720-200608000-00006.

UpToDate: Anterior temporal lobectomy complications

Anterior temporal lobectomy complications

Anterior temporal lobectomy is often complicated by quadrantanopia. In some cases this can be severe enough to prohibit driving, even if a patient is free of seizures. These deficits are caused by damage to Meyers loop of the optic radiation, which shows considerable heterogeneity in its anterior extent. This structure cannot be distinguished using clinical magnetic resonance imaging sequences.

Optic radiation tractography by DTI could be a useful method to assess an individual patient’s risk of postoperative visual deficit 1)2).

van Lanen et al., developed a score method for the assessment of postoperative visual field defects after temporal lobe epilepsy surgery and assessed its feasibility for clinical use. A significant correlation between VFD and resection size for right-sided ATL was confirmed 3).

Cranial nerve (CN) deficits following anterior temporal lobectomy (ATL) are an uncommon but well-recognized complication. The usual CNs implicated in post-ATL complications include the oculomotor nervetrochlear nerve, and facial nerves.

Injury to the trigeminal nerve leading to neuropathic pain are described in 2 cases following temporal lobe resections for pharmacoresistant epilepsy. The possible pathophysiological mechanisms are discussed and the microsurgical anatomy of surgically relevant structures is reviewed.4).

Complications

Dickerson et al., from the Department of Neurosurgery, University of Mississippi Medical Center, JacksonUSA report the third known case and first of diffuse vasospasm. A 48-year-old woman underwent a transcortical anterior left temporal lobectomy. Eleven days later, she had new-onset expressive aphasia with narrowing of the anterior, middle, and posterior cerebral arteries, and increased velocities via transcranial Doppler. She was treated with fluids, nimodipine, and permissive hypertension. At 6 months, her speech was near baseline. Cerebral vasospasm may represent a rare cause of morbidity after anterior temporal lobectomy; a literature review on the subject is presented 5).

References

1)

Borius PY, Roux FE, Valton L, Sol JC, Lotterie JA, Berry I. Can DTI fiber tracking of the optic radiations predict visual deficit after surgery? Clin Neurol Neurosurg. 2014 Jul;122:87-91. doi: 10.1016/j.clineuro.2014.04.017. Epub 2014 May 5. PubMed PMID: 24908224.
2)

James JS, Radhakrishnan A, Thomas B, Madhusoodanan M, Kesavadas C, Abraham M, Menon R, Rathore C, Vilanilam G. Diffusion tensor imaging tractography of Meyer’s loop in planning resective surgery for drug-resistant temporal lobe epilepsy. Epilepsy Res. 2015 Feb;110:95-104. doi: 10.1016/j.eplepsyres.2014.11.020. Epub 2014 Nov 27. PubMed PMID: 25616461.
3)

van Lanen RHGJ, Hoeberigs MC, Bauer NJC, Haeren RHL, Hoogland G, Colon A, Piersma C, Dings JTA, Schijns OEMG. Visual field deficits after epilepsy surgery: a new quantitative scoring method. Acta Neurochir (Wien). 2018 Jul;160(7):1325-1336. doi: 10.1007/s00701-018-3525-9. Epub 2018 Apr 5. PubMed PMID: 29623432; PubMed Central PMCID: PMC5995984.
4)

Gill I, Parrent AG, Steven DA. Trigeminal neuropathic pain as a complication of anterior temporal lobectomy: report of 2 cases. J Neurosurg. 2016 Apr;124(4):962-5. doi: 10.3171/2015.5.JNS15123. Epub 2015 Oct 30. PubMed PMID: 26517768.
5)

Dickerson JC, Hidalgo JA, Smalley ZS, Shiflett JM. Diffuse vasospasm after transcortical temporal lobectomy for intractable epilepsy. Acta Neurochir (Wien). 2018 Jul 10. doi: 10.1007/s00701-018-3606-9. [Epub ahead of print] PubMed PMID: 29987392.

Update: Anterior cervical discectomy and fusion complications

Anterior cervical discectomy and fusion complications

A 2-page survey was distributed to attendees at the 2015 Cervical Spine Research Society (CSRS) meeting. Respondents were asked to categorize 18 anterior cervical discectomy and fusion-related adverse events as either: “common and acceptable,” “uncommon and acceptable,” “uncommon and sometimes acceptable,” or “uncommon and unacceptable.” Results were compiled to generate the relative frequency of these responses for each complication. Responses for each complication event were also compared between respondents based on practice location (US vs. non-US), primary specialty (orthopedics vs. neurosurgery) and years in practice.
Of 150 surveys distributed, 115 responses were received (76.7% response rate), with the majority of respondents found to be US-based (71.3%) orthopedic surgeons (82.6%). Wrong level surgery, esophageal injury, retained drain, and spinal cord injury were considered by most to be unacceptable and uncommon complications. Dysphagia and adjacent segment disease occurred most often, but were deemed acceptable complications. Although surgeon experience and primary specialty had little impact on responses, practice location was found to significantly influence responses for 12 of 18 complications, with non-US surgeons found to categorize events more toward the uncommon and unacceptable end of the spectrum as compared with US surgeons.
These results serve to aid communication and transparency within the field of spine surgery, and will help to inform future quality improvement and best practice initiatives 1).

Vocal cord palsy

Cervical adjacent segment disease

Hoarseness

Hoarseness, approximately in 5% 2).

Dysphagia

Soft tissue damage due to the use of automatic retractors in MACDF is not minor and leads to general discomfort in the patient in spite of good neurological results. These problems most often occur when automatic retractors are used continuously for more than 1 hour, as well as when they are used in multiple levels. Dysphagia, dysphonia and local pain decreased with the use of transient manual blades for retraction, and with intermittent release following minimally invasive principles 3).
Postoperative dysphagia is a significant concern.
Dexamethasone, although potentially protective against perioperative dysphagia and airway compromise, could inhibit fusion, a generally proinflammatory process.

Postoperative hemorrhage

Cerebrospinal fluid (CSF) leaks

Cerebrospinal fluid (CSF) leaks, although uncommon, may occur and can be a potentially serious complication. Little is known regarding the fusion rate after durotomy in ACDF.
In a single-institution retrospective review, 14 patients who experienced CSF leak after ACDF between 1995 and September 2014 were identified.
The median follow-up was 13.1 months. The diagnoses included spondylosis/degenerative disc disease (n = 10), disc herniation with radiculopathy (n = 3), and kyphotic deformity (n = 1). Of ACDFs, 7 were 1-level, 5 were 2-level, and 2 were 3-level procedures. The posterior longitudinal ligament was intentionally opened in all cases, and the microscope was used in 9 cases. Durotomy was discovered intraoperatively in all cases and was generally repaired with a combination of fibrin glue and synthetic dural replacement. Lumbar drainage was used in 5 patients, and 3 patients reported orthostatic headaches, which resolved within 1 month. Two patients reported hoarseness, and 8 patients reported dysphagia; all cases were transient. Follow-up imaging for fusion assessment was available for 12 patients, and a 100% fusion rate was achieved with no postoperative infections.
ACDFs with CSF leak had a 100% fusion rate in this series, with generally excellent clinical outcomes, although it is difficult to conclude definitively that there is no effect on fusion rates because of the small sample size. However, given the relative rarity of this complication, this study provides important data in the clinical literature regarding outcomes after CSF leak in ACDFs 4).

Pharyngoesophageal perforation

Spinal subdural hematoma

A spinal subdural hematoma is a rare clinical entity with considerable consequences without prompt diagnosis and treatment. Throughout the literature, there are limited accounts of spinal subdural hematoma formation following spinal surgery. This report is the first to describe the formation of a spinal subdural hematoma in the thoracic spine following surgery at the cervical level. A 53-year-old woman developed significant paraparesis several hours after anterior cervical discectomy and fusion of C5-6. Expeditious return to operating room for anterior cervical revision decompression was performed, and the epidural hematoma was evacuated without difficulty. Postoperative imaging demonstrated a subdural hematoma confined to the thoracic level, and the patient was returned to the operating room for a third surgical procedure. Decompression of T1-3, with evacuation of the subdural hematoma was performed. Postprocedure, the patient’s sensory and motor deficits were restored, and, with rehabilitation, the patient gained functional mobility. Spinal subdural hematomas should be considered as a rare but potential complication of cervical discectomy and fusion. With early diagnosis and treatment, favorable outcomes may be achieved 5).

Carotid artery compression

Legatt et al., report herein a case of anterior cervical discectomy and fusion (ACDF) surgery in which findings on somatosensory evoked potential(SSEP) monitoring led to the correction of carotid artery compression in a patient with a vascularly isolated hemisphere (no significant collateral blood vessels to the carotid artery territory). The amplitude of the cortical SSEP component to left ulnar nerve stimulation progressively decreased in multiple runs, but there were no changes in the cervicomedullary SSEP component to the same stimulus. When the lateral (right-sided) retractor was removed, the cortical SSEP component returned to baseline. The retraction was then intermittently relaxed during the rest of the operation, and the patient suffered no neurological morbidity. Magnetic resonance angiography demonstrated a vascularly isolated right hemisphere. During anterior cervical spine surgery, carotid artery compression by the retractor can cause hemispheric ischemia and infarction in patients with inadequate collateral circulation. The primary purpose of SSEP monitoring during ACDF surgery is to detect compromise of the dorsal column somatosensory pathways within the cervical spinal cord, but intraoperative SSEP monitoring can also detect hemispheric ischemia. Concurrent recording of cervicomedullary SSEPs can help differentiate cortical SSEP changes due to hemispheric ischemia from those due to compromise of the dorsal column pathways. If there are adverse changes in the cortical SSEPs but no changes in the cervicomedullary SSEPs, the possibility of hemispheric ischemia due to carotid artery compression by the retractor should be considered 6).

Heterotopic Ossification

Heterotopic ossification (HO) has been reported following total hip, knee, cervical arthroplasty, and lumbar arthroplasty, as well as following posterolateral lumbar fusion using recombinant human morphogenetic protein 2 (rhBMP-2). Data regarding HO following anterior cervical discectomy and fusion (ACDF) with rhBMP-2 are sparse. A subanalysis was done of the prospective, multicenter, investigational device exemption trial that compared rhBMP-2 on an absorbable collagen sponge (ACS) versus allograft in ACDF for patients with symptomatic single-level cervical degenerative disc disease.
To assess differences in types of HO observed in the treatment groups and effects of HO on functional and efficacy outcomes, clinical outcomes from previous disc replacement studies were compared between patients who received rhBMP-2/ACS versus allograft. Rate, location, grade, and size of ossifications were assessed preoperatively and at 24 months, and correlated with clinical outcomes. RESULTS Heterotopic ossification was primarily anterior in both groups. Preoperatively in both groups, and including osteophytes in the target regions, HO rates were high at 40.9% and 36.9% for the rhBMP-2/ACS and allograft groups, respectively (p = 0.350). At 24 months, the rate of HO in the rhBMP-2/ACS group was higher than in the allograft group (78.6% vs 59.2%, respectively; p < 0.001). At 24 months, the rate of superior-anterior adjacent-level Park Grade 3 HO was 4.2% in both groups, whereas the rate of Park Grade 2 HO was 19.0% in the rhBMP-2/ACS group compared with 9.8% in the allograft group. At 24 months, the rate of inferior-anterior adjacent-level Park Grade 2/3 HO was 11.9% in the rhBMP-2/ACS group compared with 5.9% in the allograft group. At 24 months, HO rates at the target implant level were similar (p = 0.963). At 24 months, the mean length and anteroposterior diameter of HO were significantly greater in the rhBMP-2/ACS group compared with the allograft group (p = 0.033 and 0.012, respectively). Regarding clinical correlation, at 24 months in both groups, Park Grade 3 HO at superior adjacent-level disc spaces significantly reduced range of motion, more so in the rhBMP-2/ACS group. At 24 months, HO negatively affected Neck Disability Index scores (excluding neck/arm pain scores), neurological status, and overall success in patients in the rhBMP-2/ACS group, but not in patients in the allograft group.
Implantation of rhBMP-2/ACS at 1.5 mg/ml with polyetheretherketone spacer and titanium plate is effective in inducing fusion and improving pain and function in patients undergoing ACDF for symptomatic single-level cervical degenerative disc disease. At 24 months, the rate and dimensions (length and anteroposterior diameter) of HO were higher in the rhBMP-2/ACS group. At 24 months, range of motion was reduced, with Park Grade 3 HO in both treatment groups. The impact of Park Grades 2 and 3 HO on Neck Disability Index success, neurological status, and overall success was not consistent among the treatment groups. The study data may offer a deeper understanding of HO after ACDF and may pave the way for improved device designs 7).

Subsidence

There is evidence documenting relatively frequent complications in stand-alone cage assisted ACDF, such as cage subsidence and cervical kyphosis 8).
Subsidence irrespective of the measurement technique or definition does not appear to have an impact on successful fusion and/or clinical outcomes. A validated definition and standard measurement technique for subsidence is needed to determine the actual incidence of subsidence and its impact on radiographic and clinical outcomes 9).


The results of a observational study were in accordance with those of the published randomized controlled trials (RCTs), suggesting substantial pain reduction both after anterior cervical interbody fusion (AIF) and Cervical total disc replacement, with slightly greater benefit after arthroplasty. The analysis of atypical patients suggested that, in patients outside the spectrum of clinical trials, both surgical interventions appeared to work to a similar extent to that shown for the cohort in the matched study. Also, in the longer-term perspective, both therapies resulted in similar benefits to the patients 10).

Case series

Analysis of 1000 consecutive patients undergoing Anterior cervical discectomy and fusion (ACDF) in an outpatient setting demonstrated surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in 4-hour ASC PACU window. Comparison with inpatient ACDF surgery cohort demonstrated similar results, highlighting that ACDF can be safely performed in an outpatient ambulatory surgery setting without compromising surgical safety. To decrease cost of care, surgeons can safely consider performing 1- and 2-level ACDF in an ASC environment 11).


A retrospective case series of 37 patients, paying special attention to immediate complications related to the use of mechanical retraction of soft tissue (dysphagia, dysphonia, esophageal lesions and local hematoma); and a comparative analysis of the outcomes after changes in the retraction method.
All selected cases had a positive neurological symptom response in relation to neuropathic pain. Dysphagia and dysphonia were found during the first 72 h in 94.1% of the cases in which automatic mechanical retraction was used for more than one hour during the surgical procedure. A radical change was noted in the reduction of the symptoms after the use of only manual protective blades without automatic mechanical retraction: 5.1% dysphagia and 0% dysphonia in the immediate post-operative period, P = 0.001.
Soft tissue damage due to the use of automatic retractors in MACDF is not minor and leads to general discomfort in the patient in spite of good neurological results. These problems most often occur when automatic retractors are used continuously for more than 1 hour, as well as when they are used in multiple levels. Dysphagia, dysphonia and local pain decreased with the use of transient manual blades for retraction, and with intermittent release following minimally invasive principles 12).
1)

Wilson JR, Radcliff K, Schroeder G, Booth M, Lucasti C, Fehlings M, Ahmad N, Vaccaro A, Arnold P, Sciubba D, Ching A, Smith J, Shaffrey C, Singh K, Darden B, Daffner S, Cheng I, Ghogawala Z, Ludwig S, Buchowski J, Brodke D, Wang J, Lehman RA, Hilibrand A, Yoon T, Grauer J, Dailey A, Steinmetz M, Harrop JS. Frequency and Acceptability of Adverse Events After Anterior Cervical Discectomy and Fusion: A Survey Study From the Cervical Spine Research Society. Clin Spine Surg. 2018 Apr 27. doi: 10.1097/BSD.0000000000000645. [Epub ahead of print] PubMed PMID: 29708891.
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Morpeth JF, Williams MF. Vocal fold paralysis after anterior cervical diskectomy and fusion. Laryngoscope. 2000 Jan;110(1):43-6. PubMed PMID: 10646714.
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Ramos-Zúñiga R, Díaz-Guzmán LR, Velasquez S, Macías-Ornelas AM, Rodríguez-Vázquez M. A microsurgical anterior cervical approach and the immediate impact of mechanical retractors: A case control study. J Neurosci Rural Pract. 2015 Jul-Sep;6(3):315-9. doi: 10.4103/0976-3147.158748. PubMed PMID: 26167011; PubMed Central PMCID: PMC4481782.
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Elder BD, Theodros D, Sankey EW, Bydon M, Goodwin CR, Wolinsky JP, Sciubba DM, Gokaslan ZL, Bydon A, Witham TF. Management of Cerebrospinal Fluid Leakage During Anterior Cervical Discectomy and Fusion and Its Effect on Spinal Fusion. World Neurosurg. 2015 Nov 30. pii: S1878-8750(15)01588-0. doi: 10.1016/j.wneu.2015.11.033. [Epub ahead of print] PubMed PMID: 26654925.
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Protzman NM, Kapun J, Wagener C. Thoracic spinal subdural hematoma complicating anterior cervical discectomy and fusion: case report. J Neurosurg Spine. 2015 Oct 13:1-5. [Epub ahead of print] PubMed PMID: 26460756.
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Legatt AD, Laarakker AS, Nakhla JP, Nasser R, Altschul DJ. Somatosensory evoked potential monitoring detection of carotid compression during ACDF surgery in a patient with a vascularly isolated hemisphere. J Neurosurg Spine. 2016 Nov;25(5):566-571. PubMed PMID: 27285667.
7)

Arnold PM, Anderson KK, Selim A, Dryer RF, Kenneth Burkus J. Heterotopic ossification following single-level anterior cervical discectomy and fusion: results from the prospective, multicenter, historically controlled trial comparing allograft to an optimized dose of rhBMP-2. J Neurosurg Spine. 2016 Sep;25(3):292-302. doi: 10.3171/2016.1.SPINE15798. Epub 2016 Apr 29. PubMed PMID: 27129045.
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Cloward RB: The anterior approach for removal of ruptured cervical disks. 1958. J Neurosurg Spine 6:496-511, 2007
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Karikari IO, Jain D, Owens TR, Gottfried O, Hodges TR, Nimjee SM, Bagley CA. Impact of Subsidence on Clinical Outcomes and Radiographic Fusion Rates in Anterior Cervical Discectomy and Fusion: A Systematic Review. J Spinal Disord Tech. 2014 Feb;27(1):1-10. PubMed PMID: 24441059.
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Staub LP, Ryser C, Röder C, Mannion AF, Jarvik JG, Aebi M, Aghayev E. Total disc arthroplasty versus anterior cervical interbody fusion: use of the spine tango registry to supplement the evidence from RCTs. Spine J. 2015 Dec 7. pii: S1529-9430(15)01763-5. doi: 10.1016/j.spinee.2015.11.056. [Epub ahead of print] PubMed PMID: 26674445.
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McGirt MJ, Mehrlich M, Parker SL, Asher AL, Adamson TE. 165 ACDF in the Outpatient Ambulatory Surgery Setting: Analysis of 1000 Consecutive Cases and Comparison to Hospital Inpatient ACDF. Neurosurgery. 2015 Aug;62 Suppl 1:220. doi: 10.1227/01.neu.0000467129.12773.a3. PubMed PMID: 26182011.

Update: Anterior cerebral artery infarct

Anterior cerebral artery infarct

Stroke in the anterior cerebral artery territory are much less common than either middle cerebral artery or posterior cerebral artery territory infarcts.

Epidemiology

ACA territory infarcts are rare, comprising ~2% of ischaemic strokes.
ACA territory infarcts are less common because if the A1 segment is occluded there is generally enough collateral flow via the contralateral A1 segment to supply the distal ACA territory.

Etiology

Embolic strokes (often with MCA involvement) are the most common cause.
Rarely, they are also seen as a complication of severe midline shift, where the ACA is occluded by mass effect or severe vasospasm.
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 anterior communicating artery aneurysm (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 Anterior communicating artery aneurysm endovascular treatment, 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 (http://www.drks.de/) 1).

Clinical features

Diagnosis

The features are those of cerebral infarction in the anterior cerebral artery vascular territory:
Paramedian frontoparietal cerebral cortex
Anterior corpus callosum.
Anterior limb of the internal capsule.
Inferior portion of the Caudate nucleus head.

Differential diagnosis

Case series

Kumral et al. studied 48 consecutive patients who admitted to the stroke unit over a 6-year period.
They performed magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in all patients, and Diffusion weighted magnetic resonance imaging (DWI) in 21. In the stroke registry, patients with ACA infarction represented 1.3% of 3705 patients with ischemic stroke. The main risk factors of ACA infarcts was hypertension in 58% of patients, diabetes mellitus in 29%, hypercholesterolemia in 25%, cigarette smoking in 19%, atrial fibrillation in 19%, and myocardial infarct in 6%. Presumed causes of ACA infarct were large-artery disease and cardioembolism in 13 patients each, small-artery disease (SAD) in the territory of Heubner’s artery in two and atherosclerosis of large-arteries (<50% stenosis) in 16. On clinico-radiologic analysis there were three main clinical patterns depending on lesion side; left-side infarction (30 patients) consisting of mutism, transcortical motor aphasia, and hemiparesis with lower limb predominance; right side infarction (16 patients) accompanied by acute confusional state, motor hemineglect and hemiparesis; bilateral infarction (two patients) presented with akinetic mutism, severe sphincter dysfunction, and dependent functional outcome. Our findings suggest that clinical and etiologic spectrum of ACA infarction may present similar features as that of middle cerebral artery infarction, but frontal dysfunctions and callosal syndromes can help to make a clinical differential diagnosis. Moreover, at the early phase of stroke, DWI is useful imaging method to locate and delineate the boundary of lesion in the territory of ACA 3).
1)

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.
3)

Kumral E, Bayulkem G, Evyapan D, Yunten N. Spectrum of anterior cerebral artery territory infarction: clinical and MRI findings. Eur J Neurol. 2002 Nov;9(6):615-24. PubMed PMID: 12453077.

Update: Anterior communicating artery aneurysm 

Epidemiology

The anterior communicating artery aneurysm cause aneurysmal subarachnoid hemorrhage, in about 21.0%~25.5% of spontaneous subarachnoid hemorrhage 1) 2) 3).
Saccular aneurysms are most common in the anterior communicating artery (ACoA).
Frequently it is a wide necked aneurysm with an irregular shape, incorporate parent vessels, and are associated with significant variations in vascular anatomy.


The most common site of rupture of very small intracranial aneurysms was the anterior communicating artery (ACoA). Rupture of small and very small aneurysms is unpredictable, and treatment may be considered in selected high-risk patients according to factors such as young age, ACoA location, and hypertension 4).

Classification

Anterior communicating artery aneurysms frequently present wide aneurysm necks and incorporate parent vessels. They are associated with significant variations in vascular anatomy, especially hypoplasia or aplasia of one of the proximal anterior cerebral artery.

Morphological Scoring System of Choi


Very small intracranial aneurysm (< 3 mm)
Small intracranial aneurysm (< 5 mm)
Medium sized intracranial aneurysm (5-9.9 mm)
Large or Giant intracranial aneurysm (> 10 mm)



According to 2D-DSA, the points of aneurysm are divided into 5 types 5) 6).
Chen et al., classified as Type I, II (IIa, IIb), III and IV, based on the various projections and size of aneurysm. The principle for the choice of operative side was designed based on the type of aneurysm and the A2 fork orientation (the interrelations between the plane of bilateral A2, AComA, and mid-saggital plane) 7).
Small aneurysms located at the anterior communicating artery carry significant procedural challenges due to a complex anatomy.

Inferior or downward direction

Posterior or backward direction

Etiology

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 8).

Rupture risk

Vascular imaging was evaluated with 3D Slicer© to generate models of the aneurysms and surrounding vasculature. Morphological parameters were examined using univariate and multivariate analysis and included aneurysm volume, aspect ratio, size ratio, distance to bifurcation, aneurysm angle, vessel angle, flow angle, and parent-daughter angle. Multivariate logistic regression revealed that size ratio, flow angle, and parent-daughter angle were associated with aneurysm rupture after adjustment for age, sex, smoking history, and other clinical risk factors. Simple morphological parameters such as size ratio, flow angle, and parent-daughter angle may thus aid in the evaluation of rupture risk of anterior communicating artery aneurysms 9).

Clinical features

These aneurysms are usually silent until they rupture.
Suprachiasmatic pressure may cause altitudinal visual field deficits, abulia or akinetic mutism, amnestic syndromes, or hypothalamic dysfunction.
Neurologic deficits in aneurysmal rupture may reflect intraventricular hemorrhage (79%), brain hemorrhage (63%), acute hydrocephalus (25%), or frontal lobe signs (20%).

Visual symptoms

The AComA aneurysms rupture before becoming large enough to compress visual pathways, hence they present with aneurysmal subarachnoid hemorrhage rather than visual symptoms 10).
Giant AComA aneurysms are extremely rare and may present with vision loss 11).
Visual apparatus compression can occur from giant AComA aneurysm directed posteriorly and inferiorly 12).
The pattern of visual loss in these cases is variable. The common pattern of visual loss is bilateral field deficits.
The other patterns of visual loss due to AComA aneurysms are central scotoma, bilateral heteronymous deficits, monocular or binocular inferior field loss, asymmetrical bitemporal hemianopsia, and incongruous homonymous hemianopsia 13).

Diagnosis

Weisberg reviewed the CT findings in 40 patients with ruptured aneurysms of the anterior cerebral or anterior communicating arteries. Within 3 days of the ictus, the common patterns included blood in the pericallosal cistern and interhemispheric fissure, blood in the caval-septal region, unilateral or bilateral frontal hematoma, and diffuse symmetric intraventricular and basal cisternal blood 14).

For CT classification see the Modified Fisher scale.

Treatment

Endovascular coiling (EC) resulted in a more favorable clinical outcome, and microsurgical clipping (MC) resulted in more robust aneurysm repair, for unruptured ACoA aneurysms. Stent assisted coiling (SAC) had a higher treatment morbidity risk than EC, without reduction in retreatment rate. All treatments were effective in preventing SAH. The current pooled analysis of treatment outcomes provides a useful aid to pretreatment clinical decision making 15).

Endovascular treatment

Surgery

Complications

Cognitive deficits

In a retrospective follow-up study covering a time period of four years 18 patients operated upon early for an aneurysm of the anterior communicating artery (ACoA) and a control group of 21 patients with aneurysmal subarachnoid haemorrhage (SAH) from other sources than ACoA aneurysm and 9 patients with SAH of nonaneurysmal origin were subjected to neuropsychological examination. Both groups were comparable in their neurological condition on admission and in the severity of bleeding seen on CT-scan. Testing included memory functions, concentration, logical and spatial thinking, a Stroop-test, an aphasia screening test and a complex choice reaction task. Patients with SAH of a ruptured ACoA aneurysm did not differ significantly from the control group in any of the tests used. But there was a trend for the ACoA patients to have more memory problems than the patients with SAH of other origins. On the other hand the patients in the control group with aneurysmal SAH of other locations and with non-aneurysmal SAH had not significantly more problems with concentration and aphasia than the patients with ruptured ACoA aneurysm. These results, which differ from the common opinion of frequent occurrence of memory deficits in ACoA aneurysms are interpreted as a consequence of the changes in improved pre-, intra- and postoperative management in modern neurosurgery 16).

Case series

2017

Digital subtraction angiography images were reviewed for 204 patients with either a ruptured or an unruptured ACoA aneurysm. The ratio of the width of the larger A1 segment of the anterior cerebral artery to the smaller A1 segment was calculated. Patients with an A1 ratio greater than 2 were categorized as having A1 segment hypoplasia. The relationship of A1 segment hypoplasia to both patient and aneurysm characteristics was then assessed.
Of 204 patients that presented with an ACoA aneurysm, 34 (16.7%) were found to have a hypoplastic A1. Patients with A1 segment hypoplasia were less likely to have a history of smoking (44.1% vs 62.9%, p = 0.0410). ACoA aneurysms occurring in the setting of a hypoplastic A1 were also found to have a larger maximum diameter (mean 7.7 vs 6.0 mm, p = 0.0084). When considered as a continuous variable, increasing A1 ratio was associated with decreasing aneurysm dome-to-neck ratio (p = 0.0289). There was no significant difference in the prevalence of A1 segment hypoplasia between ruptured and unruptured aneurysms (18.9% vs 10.7%; p = 0.1605).
The results suggest that a hypoplastic A1 may affect the morphology of ACoA aneurysms. In addition, the relative lack of traditional risk factors for aneurysm formation in patients with A1 segment hypoplasia argues for the importance of hemodynamic factors in the formation of ACoA aneurysms in this anatomical setting 17).


Between January 2008 and May 2016, information on 179 consecutive patients with unruptured AcoA aneurysms was obtained and included demographic data, aneurysm features, risk factors for formation and rupture, treatment type, complications, and follow-up information. A 2-tailed t test was used for continuous data and the chi-square test for categorical variables. Statistical significance was set at P value < 0.05.
There were 76 patients 65 and older (42.5%) and 103 younger than 65 (57.5%). Conservative management was more common in older patients (67.1% vs 41.7%, P=0.001). Endovascular treatment was more commonly used in the older population (80% vs 61% of the treated aneurysms in older and younger group, P=0.16). Treatment-related complications were 8% but resulted in permanent neurological deficits in one patient (1.2%). Among conservatively treated aneurysms, three (3.2%) ruptured at follow-up resulting in patient death in two cases (2.4%). All three ruptures occurred in elderly patients.
With a modern approach that emphasizes endovascular therapy, especially in older individuals, unruptured AcoA aneurysms can be treated with a very low morbidity. Among patients with small aneurysms for which treatment was not deemed indicated or necessary, the rate of rupture at follow-up was not negligible, with 5.8% of older patients experiencing bleeding from the aneurysm 18).


Colby et al., retrospectively reviewed an IRB-approved database of patients with an aneurysm at a single institution for patients with ACoA or A1-A2 aneurysms treated with PED. Data analyzed included demographics, aneurysm characteristics, procedural details, follow-up results, and outcomes.
A total of 50 procedures were performed on 41 patients, including seven patients who underwent bilateral ‘H-pipe’ PED placement. The average age was 56 years and 46% of the patients were female. The average aneurysm size was 4.5 mm, and two large (>10 mm) aneurysms were treated. The vessel of origin was either the ACoA (26 aneurysms, 63%) or the A1-A2 junction (15 aneurysms, 37%). Eighteen patients (44%) had prior subarachnoid hemorrhage and 20 had previously been treated either with clipping (6 aneurysms, 15%) or coiling (14 aneurysms, 34%). Procedural success was achieved in 48/50 cases (96%) and two cases were aborted. Coils were deployed adjunctively in two cases (4%). Procedural outcomes included no deaths, one major ischemic stroke (2%), and two patients with intracranial hemorrhage (4%). Complete aneurysm occlusion was achieved in 81% of patients at 6 months and 85% of patients at last follow-up digital subtraction angiography.
The PED can be used safely and effectively in the treatment of aneurysms of the ACoA region. This represents a good alternative treatment option to microsurgical clipping and endovascular coiling 19).

2016

A prospectively maintained single-institution neuroendovascular database was accessed to identify consecutive cases of very small (<3 mm) ruptured anterior communicating artery aneurysms treated endovascularly between 2006 and 2013.
A total of 20 patients with ruptured very small (<3 mm) anterior communicating artery aneurysms were consecutively treated with coil embolization. The average maximum diameter was 2.66 ± 0.41 mm. Complete aneurysm occlusion was achieved for 17 (85%) aneurysms and near-complete aneurysm occlusion for 3 (15%) aneurysms. Intraoperative perforation was seen in 2 (10%) patients without any clinical worsening or need for an external ventricular drain. A thromboembolic event occurred in 1 (5 %) patient without clinical worsening or radiologic infarct. Median clinical follow-up was 12 (±14.1) months and median imaging follow-up was 12 (±18.4) months.
This report describes the largest series of consecutive endovascular treatments of ruptured very small anterior communicating artery aneurysms. These findings suggest that coil embolization of very small aneurysms in this location can be performed with acceptable rates of complications and recanalization 20).


Between January 2008 and February 2015, 254 consecutive patients with 255 ACoA aneurysms were treated with coiling. We retrospectively reviewed intraoperative angiograms and medical records to identify intraprocedural rupture and thrombus formation, and re-measured aneurysm morphologies using CT angiography images. Multivariate logistic regression models were used to determine independent predictors of intraprocedural rupture and thrombus formation.
Of the 231 patients included, intraprocedural rupture occurred in 10 (4.3%) patients, and thrombus formation occurred in 15 (6.5%) patients. Patients with smaller aneurysms more often experienced intraprocedural rupture than those with larger aneurysms (3.5±1.3 mm vs 5.7±2.3 mm). Multivariate analysis showed that smaller ruptured aneurysms (p=0.003) were independently associated with intraprocedural rupture. The threshold of aneurysm size separating rupture and non-rupture groups was 3.5 mm. Multivariate analysis showed that a history of hypertension (p=0.033), aneurysm neck size (p=0.004), and parent vessel angle (p=0.023) were independent predictors of thrombus formation. The threshold of parent vessel angle separating thrombus and non-thrombus groups was 60.0°.
Ruptured aneurysms <3.5 mm were associated with an increased risk of intraprocedural rupture, and parent vessel angle <60.0°, wider-neck aneurysms, and a history of hypertension were associated with increased risk of thrombus formation during coiling of ruptured ACoA aneurysms21).

2009

In 33 cases among 351 cases of ruptured anterior communicating artery aneurysms treated surgically, from 1991 to 2000, the dome of aneurysm was compressed in optic pathway. In some cases, aneurysm impacted into the optic nerve that deep hollowness was found when the aneurysm sac was removed during operation. Among 33 cases, 10 cases presented with preoperative visual symptoms, such as visual dimness (5), unilateral visual field defect (2) or unilateral visual loss (3), 20 cases had no visual symptoms. Visual symptoms could not be checked in 3 cases due to the poor mental state. In 6 cases among 20 cases having no visual symptoms, optic nerve was deeply compressed by the dome of aneurysm which was seen in the surgical field. Of 10 patients who had visual symptoms, 8 showed improvement in visual symptoms within 6 months after clipping of aneurysms. In 2 cases, the visual symptoms did not recover.
Anterior communicating artery aneurysm can cause visual symptoms by compressing the optic nerve or direct rupture to the optic nerve with focal hematoma formation. Park et al., emphasize that cerebral vascular study is highly recommended to detect intracranial aneurysm before its rupture in the case of normal CT findings with visual symptoms and frequent headache 22).

2003

A prospective study included 223 patients who were divided into three groups: Group A (83 microsurgically treated patients, 1990-1995); Group B (103 microsurgically treated patients, 1996-2000); and Group C (37 patients treated with Guglielmi Detachable Coil [GDC] embolization, 1996-2000). Depending on the direction in which the aneurysm fundus projected, the authors attempted to apply microsurgical treatment to Type 1 aneurysms (located in front of the axis formed by the pericallosal arteries). They proposed the most adapted procedure for Type 2 aneurysms (located behind the axis of the pericallosal arteries) after discussion with the neurovascular team, depending on the physiological status of the patient, the treatment risk, and the size of the aneurysm neck. In accordance with the classification of Hunt and Hess, the authors designated those patients with unruptured aneurysms (Grade 0) and some patients with ruptured aneurysms (Grades I-III) as having good preoperative grades. Patients with Grade IV or V hemorrhages were designated as having poor preoperative grades. By performing routine angiography and computerized tomography scanning, the causes of unfavorable outcome (Glasgow Outcome Scale [GOS] score < 5) and the morphological results (complete or incomplete occlusion) were analyzed. Overall, the clinical outcome was excellent (GOS Score 5) in 65% of patients, good (GOS Score 4) in 9.4%, fair (GOS Score 3) in 11.6%, poor (GOS Score 2) in 3.6%, and fatal in 10.3% (GOS Score 1). Among 166 patients in good preoperative grades, an excellent outcome was observed in 134 patients (80.7%). The combined permanent morbidity and mortality rate accounted for up to 19.3% of patients. The rates of permanent morbidity and death that were related to the initial subarachnoid hemorrhage were 6.2 and 1.5% for Group A, 6.6 and 1.3% for Group B, and 4 and 4% for Group C, respectively. The rates of permanent morbidity and death that were related to the procedure were 15.4 and 1.5% for Group A, 3.9 and 0% for Group B, and 8 and 8% for Group C, respectively. When microsurgical periods were compared, the rate of permanent morbidity or death related to microsurgical complications decreased significantly (Group A, 11 patients [16.9%] and Group B, three patients [3.9%]); Fisher exact test, p = 0.011) from the period of 1990 to 1995 to the period of 1996 to 2000. The combined rate of morbidity and mortality that was related to the endovascular procedure (16%) explained the nonsignificance of the different rates of procedural complications for the two periods, despite the significant decrease in the number of microsurgical complications. Among 57 patients in poor preoperative grade, an excellent outcome was observed in 11 patients (19.3%); however, permanent morbidity (GOS Scores 2-4) or death (GOS Score 1) occurred in 46 patients (80.7%). With regard to the correlation between vessel occlusion (the primary microsurgical complication) and the morphological characteristics of aneurysms, only the direction in which the fundus projected appeared significant as a risk factor for the microsurgically treated groups (Fisher exact test: Group A, p = 0.03; Group B, p = 0.002). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (chi2 = 6.13, p = 0.01).
The direction in which the fundus projects was chosen as the morphological criterion between endovascular and surgical methods. The authors propose that microsurgical clip application should be the preferred option in the treatment of ACoA aneurysms with anteriorly directed fundi and that endovascular packing be selected for those lesions with posteriorly directed fundi, depending on morphological criteria 23).

Case reports

2016

Cohen et al., describe a technique for T-configured stent-assisted coiling in the management of ruptured wide-necked AcomA aneurysms by means of two simultaneous microsystems that allowed placement of two nitinol self-expandable Leo+ Baby stents (Balt Therapeutics, Montmorency, France) followed by coiling. Technical details and comparison to other dual stent configurations were presented and briefly discussed 24).


A 69-year-old male without a past history of mental disorders and neurological symptoms presented with a 2-month history of anxiety, sadness, lack of pleasure in usual activities, fatigue, difficulties falling asleep and waking up early in the morning, reduced appetite, and weight loss. The patient was diagnosed with major depressive disorder and antidepressant treatment was initiated. Subsequent non-contrast computed tomography (CT) of the head demonstrated hypointense oval-shaped lesion within the projection of the anterior communicating artery. CT angiography confirmed the diagnosis of a 0.8 × 0.6 cm saccular aneurysm originating from the anterior communicating artery and anterior cerebral artery. The patient underwent microsurgical clipping of the aneurysm. On psychiatric assessment 1 month after the surgery, there were no signs of depressive disorder and antidepressive treatment was discontinued. On follow-up visit 1 year after the surgery, the patient did not have any mood symptoms.
The case indicates that organic brain lesions, including intracranial aneurysms, should be suspected in elderly patients presenting with their first episode of mental disorder 25).

2015

Seung et al., present an unusual case of bitemporal hemianopsia caused by a large intracranial aneurysm of the ACoA. A 41-year-old woman was admitted to our neurosurgical department with a sudden-onset bursting headache and visual impairment. On admission, her vision was decreased to finger counting at 30 cm in the left eye and 50 cm in the right eye, and a severe bitemporal hemianopsia was demonstrated on visual field testing. A brain computed tomography scan revealed a subarachnoid hemorrhage at the basal cistern, and conventional cerebral catheter angiography of the left internal carotid artery demonstrated an 18×8 mm dumbbell-shaped aneurysm at the ACoA. Microscopic aneurysmal clipping was performed. An ACoA aneurysm can produce visual field defects by compressing the optic chiasm or nerves. We emphasize that it is important to diagnose an aneurysm through cerebrovascular study to prevent confusing it with pituitary apoplexy 26).


A 55-year-old man presented with a 3-year history of visual impairment associated with personality changes. His sister had died after an intracerebral aneurysmal rupture. An examination revealed poor visual acuity in the right eye with a field defect, as well as impaired neurocognition. Computed tomographic (CT) angiography (Panel A) and magnetic resonance imaging of the brain revealed a partially thrombosed, calcified, 7-cm aneurysm of the anterior communicating artery, with surrounding edema (Panel B). Thrombectomy and aneurysmal repair were performed to reduce the risk of aneurysmal rupture and to alleviate the mass effect. The patient recovered from surgery and had improvement in his neurocognitive deficits and vision, and he was able to return to work. His condition remained stable 2 years later, and delayed CT showed collapse of the aneurysmal sac (Panel C). Giant aneurysms (>2.5 cm) represent a small proportion of brain aneurysms but are associated with a high rupture rate when left untreated. Approximately 20% of patients with a brain aneurysm have a first-degree relative with a brain aneurysm 27).

1988

A study reports the case of a 42-year-old man who suffered a ruptured aneurysm of the anterior communicating artery. His memory capabilities were assessed after a considerable recovery period during which many of his memory deficits ameliorated. His scan revealed a left frontal lesion and many of his deficits were characteristic of frontal impairment. He was impaired on temporal discrimination, and he showed marked source forgetting. He also performed badly on the Brown-Peterson task, and we suggest that this is another task that may be characteristic of frontal impairment. In contrast, the patient showed normal or near normal performance on some memory tasks but not on others. It is concluded that the patient’s frontal signs are similar to those found in Korsakoff’s Syndrome, but that his memory impairment is qualitatively different from that encountered in patients with the amnesic syndrome 28).
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Suzuki M, Fujisawa H, Ishihara H, Yoneda H, Kato S, Ogawa A. Side selection of pterional approach for anterior communicating artery aneurysms–surgical anatomy and strategy. Acta Neurochir (Wien) 2008;150:31–39. 39.
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Kimura T, Morita A, Shirouzu I, Sora S. Preoperative evaluation of unruptured cerebral aneurysms by fast imaging employing steady-state acquisition image. Neurosurgery. 2011;69:412–419. discussion 419-420.
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Kwon SC, Park JB, Shin SH, Sim HB, Lyo IU, Kim Y. The Efficacy of Simultaneous Bilateral Internal Carotid Angiography during Coil Embolization for Anterior Communicating Artery Aneurysms. J Korean Neurosurg Soc. 2011;49:257–261
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Choi JH, Kang MJ, Huh JT. Influence of clinical and anatomic features on treatment decisions for anterior communicating artery aneurysms. J Korean Neurosurg Soc. 2011;50:81–88.
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Cohen JE, Gomori JM, Moscovici S, Itshayek E. Balloon-guided navigation technique to perform stenting in an acutely angled anterior cerebral artery. J Clin Neurosci. 2012;19:452–454.
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Chen L, Agrawal A, Kato Y, Karagiozov KL, Kumar MV, Sano H, Kanno T. Role of aneurysm projection in “A2” fork orientation for determining the side of surgical approach. Acta Neurochir (Wien). 2009 Aug;151(8):925-33; discussion 933. doi: 10.1007/s00701-009-0407-1. Epub 2009 Jun 5. PubMed PMID: 19499172.
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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.
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Lin N, Ho A, Charoenvimolphan N, Frerichs KU, Day AL, Du R. Analysis of morphological parameters to differentiate rupture status in anterior communicating artery aneurysms. PLoS One. 2013 Nov 13;8(11):e79635. doi: 10.1371/journal.pone.0079635. eCollection 2013. PubMed PMID: 24236149; PubMed Central PMCID: PMC3827376.
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Kasner SE, Liu GT, Galetta S. Neuroophthalmologic aspects of aneurysms. Neuroimaging Clin N Am. 1997;7:679–92.
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Lownie SP, Drake CG, Peerless SJ, Ferguson GG, Pelz DM. Clinical presentation and management of giant anterior communicating artery region aneurysms. J Neurosurg. 2000;92:267–77.
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Shukla DP, Bhat DI, Devi BI. Anterior communicating artery aneurysm presenting with vision loss. J Neurosci Rural Pract. 2013 Jul;4(3):305-7. doi: 10.4103/0976-3147.118765. PubMed PMID: 24250165; PubMed Central PMCID: PMC3821418.
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Weisberg LA. Ruptured aneurysms of anterior cerebral or anterior communicating arteries: CT patterns. Neurology. 1985 Nov;35(11):1562-6. PubMed PMID: 4058745.
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O’Neill AH, Chandra RV, Lai LT. Safety and effectiveness of microsurgical clipping, endovascular coiling, and stent assisted coiling for unruptured anterior communicating artery aneurysms: a systematic analysis of observational studies. J Neurointerv Surg. 2016 Sep 13. pii: neurintsurg-2016-012629. doi: 10.1136/neurintsurg-2016-012629. [Epub ahead of print] Review. PubMed PMID: 27624158.
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Hütter BO, Gilsbach JM. Cognitive deficits after rupture and early repair of anterior communicating artery aneurysms. Acta Neurochir (Wien). 1992;116(1):6-13. PubMed PMID: 1615771.
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Rinaldo L, McCutcheon BA, Murphy ME, Bydon M, Rabinstein AA, Lanzino G. Relationship of A(1) segment hypoplasia to anterior communicating artery aneurysm morphology and risk factors for aneurysm formation. J Neurosurg. 2017 Jul;127(1):89-95. doi: 10.3171/2016.7.JNS16736. Epub 2016 Sep 30. PubMed PMID: 27689465.
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Cagnazzo F, Brinjikji W, Lanzino G. Effect of age on outcomes and practice patterns for patients with anterior communicating artery aneurysms. J Neurosurg Sci. 2017 Jan 12. doi: 10.23736/S0390-5616.16.03942-4. [Epub ahead of print] PubMed PMID: 28079351.
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Colby GP, Bender MT, Lin LM, Beaty N, Huang J, Tamargo R, Coon A. Endovascular flow diversion for treatment of anterior communicating artery region cerebral aneurysms: a single-center cohort of 50 cases. J Neurointerv Surg. 2017 Jan 27. pii: neurintsurg-2016-012946. doi: 10.1136/neurintsurg-2016-012946. [Epub ahead of print] PubMed PMID: 28130501.
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Fan L, Lin B, Xu T, Xia N, Shao X, Tan X, Zhong M, Yang Y, Zhao B. Predicting intraprocedural rupture and thrombus formation during coiling of ruptured anterior communicating artery aneurysms. J Neurointerv Surg. 2016 Apr 5. pii: neurintsurg-2016-012335. doi: 10.1136/neurintsurg-2016-012335. [Epub ahead of print] PubMed PMID: 27183655.
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Update: Postoperative hemorrhage after anterior cervical discectomy and fusion

Postoperative hemorrhage after anterior cervical discectomy and fusion

J.Sales-Llopis
Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain
Surgeons need to be alert for this complication and try their best to prevent it 1) 2) 3) 4), because it is one of the most catastrophic complications of anterior cervical discectomy and fusion(ACDF), which may result in dyspnea, respiratory arrest, and death 5) 6) 7) 8) 9) 10).

Epidemiology

see also Anterior cervical discectomy and fusion complications.
The reported incidence of this postoperative complication has varied from 0.2% to 1.9% 11).
Fountas et al. reported that postoperative hematoma occurred in 5.6% patients who underwent ACDF, 2.4% of whom required reoperation 12).
However, Aono et al.reported an incidence of 0.21% 13).
Case reports of life-threatening circumstances and critical patients who required tracheotomy and reoperation have also been published 14) 15) 16).

Diagnosis

Neck swelling and progressive respiratory disturbance have become important, as proposed in the guidelines by Palumbo et al 17).
The results of the study of Kogure et al. indicated that indwelling drains are not necessary in patients who undergo one-level anterior cervical fixation surgery, and that observation of the prevertebral space (PVS) on simple cervical spine radiographs is the simplest and most useful method to determine any complications 18).


Basques et al. 19) measured the amount of drainage. Only a few reports have mentioned the drainage status, even in case reports of postoperative hematomas. Furthermore, one report documented the absence of drainage 20).

Bleeding point

In the early postoperative period, when bleeding from the superior thyroid artery was excluded, the point of bleeding during the time of reoperation has been unclear in many cases 21).

Prevention

Application of Floseal at the end, can significantly reduce the amount of postoperative hemorrhage 22) 23).

1) Yeom JS, Buchowski JM, Shen HX, Liu G, Bunmaprasert T, Riew KD. Effect of fibrin sealant on drain output and duration of hospitalization after multilevel anterior cervical fusion: a retrospective matched pair analysis. Spine (Phila Pa 1976) 2008;33:E543–E547.
2) Cho SK, Yi JS, Park MS, et al. Hemostatic techniques reduce hospital stay following multilevel posterior cervical spine surgery. J Bone Joint Surg Am. 2012;94:1952–1958.
3) Tsutsumimoto T, Shimogata M, Ohta H, Yui M, Yoda I, Misawa H. Tranexamic acid reduces perioperative blood loss in cervical laminoplasty: a prospective randomized study. Spine (Phila Pa 1976) 2011;36:1913–1918.
4) Schubert M, Merk S. Retrospective evaluation of efficiency and safety of an anterior percutaneous approach for cervical discectomy. Asian Spine J. 2014;8:412–420.
5) Sagi HC, Beutler W, Carroll E, Connolly PJ. Airway complications associated with surgery on the anterior cervical spine. Spine (Phila Pa 1976) 2002;27:949–953.
6) , 11) , 17) Palumbo MA, Aidlen JP, Daniels AH, Thakur NA, Caiati J. Airway compromise due to wound hematoma following anterior cervical spine surgery. Open Orthop J. 2012;6:108–113.
7) Dagli M, Er U, Simsek S, Bavbek M. Late results of anterior cervical discectomy and fusion with interbody cages. Asian Spine J. 2013;7:34–38.
8) Pallud J, Belaid H, Aldea S. Successfull management of a life threatening cerebellar haemorrhage following spine surgery: a case report. Asian Spine J. 2009;3:32–34.
9) Song KJ, Choi BY. Current concepts of anterior cervical discectomy and fusion: a review of literature. Asian Spine J. 2014;8:531–539.
10) Buerba RA, Giles E, Webb ML, Fu MC, Gvozdyev B, Grauer JN. Increased risk of complications after anterior cervical discectomy and fusion in the elderly: an analysis of 6253 patients in the American College of Surgeons National Surgical Quality Improvement Program database. Spine (Phila Pa 1976) 2014;39:2062–2069.
12) Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson JS Jr. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007 Oct 1;32(21):2310-7. Review. PubMed PMID: 17906571.
13) Aono H, Ohwada T, Hosono N, Tobimatsu H, Ariga K, Fuji T, Iwasaki M. Incidence of postoperative symptomatic epidural hematoma in spinal decompression surgery. J Neurosurg Spine. 2011 Aug;15(2):202-5. doi: 10.3171/2011.3.SPINE10716. Epub 2011 May 6. PubMed PMID: 21529204.
14) , 20) Yu NH, Jahng TA, Kim CH, Chung CK: Life-threatening late hemorrhage due to superior thyroid artery dissection after anterior cervical discectomy and fusion. Spine (Phila Pa 1976) 2010; 35: E739―E742.
15) Skovrlj B, Mascitelli JR, Camins MB, Doshi AH, Qureshi SA: Acute respiratory failure from Surgifoam expansion after anterior cervical surgery: case report. J Neurosurg Spine 2013; 19: 428―430.
16) Dedouit F, Grill S, Guilbeau-Frugier C, Savall F, Rougé D, Telmon N: Retropharyngeal hematoma secondary to cer- vical spine surgery: report of one fatal case. J Forensic Sci 2014; 59: 1427―1431.
18) , 21) Kogure K, Node Y, Tamaki T, Yamazaki M, Takumi I, Morita A. Indwelling Drains Are Not Necessary for Patients Undergoing One-level Anterior Cervical Fixation Surgery. J Nippon Med Sch. 2015;82(3):124-9. doi: 10.1272/jnms.82.124. PubMed PMID: 26156665.
19) Basques BA, Bohl DD, Golinvaux NS, Yacob A, Varthi AG, Grauer JN: Factors predictive of increased surgical drain output after anteriorcervical discectomy and fusion. Spine (Phila Pa 1976) 2014; 39: 728―735.
22) Yeom JS, Buchowski JM, Shen HX, Liu G, Bunmaprasert T, Riew KD. Effect of fibrin sealant on drain output and duration of hospitalization after multilevel anterior cervical fusion: a retrospective matched pair analysis. Spine (Phila Pa 1976). 2008 Jul 15;33(16):E543-7. doi: 10.1097/BRS.0b013e31817c6c9b. PubMed PMID: 18628695.
23) Li QY, Lee O, Han HS, Kim GU, Lee CK, Kang SS, Lee MH, Cho HG, Kim HJ, Yeom JS. Efficacy of a Topical Gelatin-Thrombin Matrix Sealant in Reducing Postoperative Drainage Following Anterior Cervical Discectomy and Fusion. Asian Spine J. 2015 Dec;9(6):909-15. doi: 10.4184/asj.2015.9.6.909. Epub 2015 Dec 8. PubMed PMID: 26713124; PubMed Central PMCID: PMC4686397.

Differences between anterior circulation aneurysm and posterior circulation intracranial aneurysm

Significant differences between anterior circulation aneurysm and posterior circulation intracranial aneurysm were found for the aspect ratio (AR) (1.91 ± 0.8 vs. 2.75 ± 1.8; p = 0.02) and for the parent artery size (5.08 ± 1.8 mm vs. 3.95 ± 1.5 mm; p < 0.05).

 
(AR = aneurysm dome depth/neck size)

h: aneurysm dome depth
n: neck size or wide
a: parent artery size
Tykocki T, Kostkiewicz B. Aneurysms of the anterior and posterior cerebral circulation: comparison of the morphometric features. Acta Neurochir (Wien). 2014 Sep;156(9):1647-54. doi: 10.1007/s00701-014-2173-y. Epub 2014 Jul 19. PubMed PMID: 25034507; PubMed Central PMCID: PMC4137168.
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Update: Anterior choroidal artery (AchA)

Anterior choroidal artery (AchA)

J.Sales-Llopis
Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain

Anatomically, the cisternal segment of the AChA originates from the posterolateral wall of the internal carotid artery (ICA), runs along the lateral recess of the basal cistern, attaches itself to the optic tract, which is follows to reach the crural cisternbefore entering the choroidal fissure.
Microdissection of 100 hemispheres from human cadavers were performed in order to study the anatomic characteristics of the anterior choroidal artery (AChA). One AChA per hemisphere was found. In 98% of hemispheres the AChA arose from the internal carotid artery (ACI) 2.4mm distal to the origin of the posterior communicating artery (ACoP) and 4.7mm proximal to the carotid bifurcation. One or more perforating branches arose from communicating segment of ACI in 29% of hemispheres. The average calibre of the cisternal portion was 0.9mm and the plexal portion 0.7mm. The most frequent branches of the cisternal portion pass to the optic tract, cerebral peduncle, uncus and lateral geniculate body. Anastomosis were found between branches of the AChA and posterior cerebral artery, ACoP, middle cerebral artery and ACI 1).

Origin

An ectopic origin was observed in 4% of cases. The intracisternal segment of the anterior choroidal a. forms a neurovascular bundle with the optic tract and basal v. Most of its intraparenchymatous branches arise from the cisternal segment, while branches supplying the optic tract, lateral geniculate body and thalamus arise from the intraplexual segment. Constant anastomoses exist with the vertebrobasilar system, specially the postero-lateral choroidal and posterior cerebral aa. 2).

Segments

Both parts of the cisternal segment of the AChA come into surgical view during surgeries for different pathologies in and around theperimesencephalic cisterns. However, attending to the artery’s genu and defining pre- and postoptic parts during surgery may help the surgeon locate the origin and eventual course of these perforators, and even estimate the terminal areas of supply of most of the perforating arteries. The proposed classification system os Tanriover et al. can prove helpful in planning any operative procedure along the crural cistern and may reduce the probability of inadvertent injury to perforating branches of the cisternal segment.
The cisternal segment of the AChA was divided into pre- and postoptic parts that meet at the artery’s genu, the most medial extension point of the cisternal segment where the artery makes an abrupt turn after passing under the optic tract. The preoptic part of the AChA extended from its origin at the inferomedial side of the internal carotid artery to the artery’s genu, which is commonly located just inferomedial to the initial part of the optic tract. The postoptic part coursed within the crural cistern and extended from the genu to the inferior choroidal point. The genu of the AChA was 8 mm medial to the artery’s origin and was located medial to the optic tract in 13% of the hemispheres. The postoptic part was longer than the preoptic part in all hemispheres and had more perforating arteries supplying critical deep structures (preoptic 3.4 per hemisphere vs postoptic 4.6 per hemisphere), and these results were statistically significant (p = 0.01). At the preoptic part, perforating arteries arose from the superolateral portion of the artery and coursed laterally; at the postoptic part, perforators arose from the inferomedial portion of the artery and coursed medially. Perforating arteries from both segments passed most commonly to the optic tract, followed by the anterior segment and apex of uncus in the preoptic part and the cerebral peduncle in the postoptic part. 3).

Structure

The anterior choroidal artery serves structures in the telencephalon, diencephalon, and mesencephalon:
choroid plexus of the lateral ventricle and third ventricle
optic chiasm and optic tract
internal capsule
lateral geniculate body
globus pallidus
tail of the caudate nucleus
hippocampus
amygdala
substantia nigra
red nucleus
crus cerebri

Clinical significance

The full extent of the damage caused by occlusion of the anterior choroidal artery is not known. However, studies show that the interruption of blood flow from this vessel can result in hemiplegia on the contralateral (opposite) side of the body, contralateral hemihypoesthesia, and homonymous hemianopsia. These symptoms are thought to arise from ischemic damage to the posterior limb of the internal capsule, thalamus, and optic chiasm/optic tract. However, the posterior limb of the internal capsule also receives lenticulostriate arteries from the Middle Cerebral Artery, thus creating partially redundant supply.

Angiography

1) Ferreira A, Braga FM. [Microsurgical anatomy of the anterior choroidal artery]. Arq Neuropsiquiatr. 1990 Dec;48(4):448-53. Review. Portuguese. PubMed PMID: 2094191.
2) Morandi X, Brassier G, Darnault P, Mercier P, Scarabin JM, Duval JM. Microsurgical anatomy of the anterior choroidal artery. Surg Radiol Anat. 1996;18(4):275-80. PubMed PMID: 8983106.
3) Tanriover N, Kucukyuruk B, Ulu MO, Isler C, Sam B, Abuzayed B, Uzan M, Ak H, Tuzgen S. Microsurgical anatomy of the cisternal anterior choroidal artery with special emphasis on the preoptic and postoptic subdivisions. J Neurosurg. 2014 May;120(5):1217-28. doi: 10.3171/2014.1.JNS131325. Epub 2014 Mar 14. PubMed PMID: 24628614.
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