Advance Access: Changing Paradigms in the Endovascular Management of Ruptured Anterior Communicating Artery Aneurysms

The endovascular treatment of anterior communicating artery (ACoA) aneurysms has evolved dramatically over the past decade.1,2 The Barrow Ruptured Aneurysm Trial (BRAT), a large-scale prospective randomized trial, compared microsurgical clip occlusion with endovascular coil embolization to determine the relative safety and efficacy of these treatments for acutely ruptured cerebral aneurysms.3 The trial included 130 ACoA patients; 91 (70%) of the patients’ aneurysms were clipped and 39 (30%) were coiled. Twenty-two of the 61 ACoA patients who were initially randomized to coiling crossed over to clipping after evaluation (17% of all 130 ACoA patients). No patients crossed over from clipping to coiling. A subset analysis demonstrated clinical equipoise between clipping and coiling for ACoA aneurysms in the trial, with no detectable differences in clinical outcomes or complications.4

The most common reasons that ruptured ACoA aneurysms were not treated with endovascular techniques were that the aneurysms were too small (<5 mm) for coils available at the time of the trial or that they had an unfavorable (<2) dome-to-neck ratio. However, improvements in balloon, coil, and catheter technology have since made navigation and embolization of ACoA aneurysms safer and more feasible.4,–7 Additionally, we have recently described our experience with balloon remodeling in this location.8 We set out to compare our experience in the endovascular management of ruptured ACoA aneurysms in BRAT with that of patients treated since the end of the trial, with an emphasis on adjunctive treatment modalities, clinical outcomes, and retreatment rates.

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