title: Endovascular therapy of very small aneurysms of the anterior communicating artery: five-fold increased incidence of rupture.
abstract: BACKGROUND
  Intraprocedural rupture is a dangerous complication of endovascular treatment. Small ruptured anterior communicating artery (ACoA) aneurysms and microaneurysms present a challenge for both surgical and endovascular therapies to achieve obliteration. An understanding of the complication rates of treating ruptured ACoA microaneurysms may help guide therapeutic options.
  
  
  OBJECTIVE
  To report the largest cohort of ACoA microaneurysms treated with endovascular therapy over the course of the past 10 years.
  
  
  METHODS
  We performed a retrospective review of 347 ACoA aneurysms treated in 347 patients at Cleveland Clinic and Emory University over a 10-year period. Patient demographics, aneurysmal rupture, size, use of balloon remodeling, patient outcomes, intraprocedural rupture, and rerupture were reviewed.
  
  
  RESULTS
  Rupture rates were examined by size for all patients and subgroups and dichotomized to evaluate for size ranges associated with increased rupture rates. The highest risk of rupture was noted in aneurysms less than 4 mm. Of 347 aneurysms, 74 (21%) were less than 4 mm. The intraprocedural rupture rate was 5% (18/347) for ACoA aneurysms of any size. There was an intraprocedural rupture rate of 2.9% (8/273) among ACoA aneurysms greater than 4 mm compared with 13.5% (10/74) in less than 4-mm aneurysms. Procedural rupture was a statistically significant predictor of modified Rankin score after adjusting for Hunt and Hess grades (HH).
  
  
  CONCLUSIONS
  ACoA aneurysms less than 4 mm have a 5-fold higher incidence of intraprocedural rerupture during coil embolization. Outcome is negatively affected by intraprocedural rerupture after adjusting for HH grade.
authors.affiliation: Department of Neurosurgery, Emory University, Atlanta, Georgia 30322, USA. ajschue@gmail.com
authors.forename: Albert J
authors.initials: AJ
authors.lastname: Schuette
authors.forename: Ferdinand K
authors.initials: FK
authors.lastname: Hui
authors.forename: Alejandro M
authors.initials: AM
authors.lastname: Spiotta
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Obuchowski
authors.forename: Rishi
authors.initials: R
authors.lastname: Gupta
authors.forename: Shaye I
authors.initials: SI
authors.lastname: Moskowitz
authors.forename: Frank C
authors.initials: FC
authors.lastname: Tong
authors.forename: Jacques E
authors.initials: JE
authors.lastname: Dion
authors.forename: Charles M
authors.initials: CM
authors.lastname: Cawley
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000453:epidemiology* / Q000517:prevention & control*; D015897:Comorbidity; D057510:Endovascular Procedures / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015994:Incidence; D002532:Intracranial Aneurysm / Q000453:epidemiology* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009820:Ohio / Q000453:epidemiology; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D055815:Young Adult