Case Report: CASE OF ANTERIOR COMMUNICATING ARTERY (A.C.O.M.) ANEURYSM

Introduction

An aneurysm is defined as a protrusion or bulge in a blood vessel that can rupture, resulting in intracranial bleeding. Anterior communicating artery (ACOM) aneurysms form at the convergence point of the internal and external carotid arteries in the brain. These represent the most common type of cerebral aneurysm, accounting for 23-40% of all cerebral aneurysms and 12-15% of unruptured aneurysms, with particularly high prevalence in patients under 30 years of age.¹

Treatment options for ACOM aneurysms include clipping, which involves surgically preventing aneurysm rupture by applying a small metal clip to its base. This procedure is typically performed under general anesthesia, requiring a small scalp incision and skull opening to access the aneurysm.² The International Study of Unruptured Intracranial Aneurysms (ISUIA) established an annual rupture risk of approximately 1% for anterior circulation aneurysms smaller than 7 mm.³ However, recent research indicates that ACOM aneurysms smaller than 7 mm carry a disproportionately high rupture risk. Bijlenga et al. examined over 900 ACOM aneurysm cases with sizes ranging from 4-7 mm and found rupture risk comparable to posterior circulation aneurysms.⁴ Lee et al. found that ACOM aneurysms were most frequently ruptured, with 47% of 200 patients with ruptured aneurysms having small (≤5 mm) aneurysms. Patients with hypertension showed an even higher propensity for microaneurysm (≤3 mm) rupture.⁵

Advances in interventional materials and techniques have expanded treatment options to include endovascular approaches such as flow diverters and embolization. However, the complex anatomy of ACOM aneurysms—characterized by poor aspect ratio, catheter insertion difficulties, and potential impact on collateral blood flow—often limits the applicability of endovascular therapy.⁶

The Barrow Ruptured Aneurysm Trial (BRAT) evaluated long-term outcomes for ACOM aneurysms, randomizing 39 patients (30%) to embolization and 91 patients (70%) to clipping. While 16.9% of embolization patients required conversion to surgical clipping due to complications, no patients transferred from clipping to embolization. After 1-3 years of follow-up, clinical outcomes were comparable between groups, though the clipping group demonstrated lower retreatment rates (3.3% vs 7.7%).⁷

Case report

The 56-year-old female patient initially presented to the private hospital with acute headache and nausea as her chief complaints. She appeared distressed but was fully alert, oriented to time, place, and person upon admission. The patient reported that her symptoms had begun suddenly and had progressively worsened over the previous 48 hours, prompting her to seek medical attention when over-the-counter pain relievers provided no relief.

The patient’s medical history was unremarkable, with no previous instances of severe headaches, neurological symptoms, or prior hospitalizations. She belonged to an intergenerational family with good overall health and denied any family history of cerebrovascular diseases, asthma, or hypertension. Social history revealed that she was a non-smoker and did not consume alcohol. She reported experiencing significant marital stress as her husband had previously been unfaithful, though she maintained good relationships with other family members.

Upon further questioning, the patient described developing sleep disturbances in the days preceding admission due to gastrointestinal and urinary discomfort. She reported experiencing pain in her abdomen and groin region, which had been intermittent at first but became more persistent as her headache worsened. She also noted mild nausea without vomiting and slight sensitivity to bright lights, though denied any fever, visual disturbances, or loss of consciousness. The patient expressed significant anxiety about her condition, particularly given its sudden onset.

Physical examination revealed a thin-framed woman measuring 152 cm in height and weighing 51 kg, with normal vital signs except for a slightly elevated pulse rate. Her blood pressure was recorded at 110/70 mmHg. The patient appeared well-groomed and maintained good personal hygiene despite her distress. Neurological examination was initially unremarkable, with no focal deficits noted. Abdominal examination revealed atypical findings without rashes, tenderness, or purulent discharge. Initial blood work showed low hemoglobin at 10 g/dl, prompting further laboratory investigations.

Comprehensive diagnostic evaluation revealed low hemoglobin (7.5 g/dl), elevated sodium (119.1 mg/dl), increased creatinine (1.4 mg), and high calcium (0.0 mg/dl). Neuroimaging studies subsequently confirmed the presence of an anterior communicating artery aneurysm. The patient was immediately started on a treatment regimen including ondansetron for nausea, hydrochlorothiazide to manage blood pressure, potassium citrate to address electrolyte imbalances, and alpha-blockers. The healthcare team discussed surgical intervention options with the patient and her family, emphasizing the importance of prompt treatment given the high rupture risk associated with ACOM aneurysms.

After thorough evaluation and consultation with the neurosurgery team, the patient was scheduled for surgical clipping of the anterior communicating artery aneurysm. The procedure was deemed necessary due to the high rupture risk associated with ACOM aneurysms, particularly given the patient’s symptom presentation. The patient and her family were counseled regarding the risks, benefits, and alternatives to surgical intervention, after which informed consent was obtained.

The patient underwent ACOM aneurysm clipping under general anesthesia. A pterional craniotomy approach was utilized to access the aneurysm. The procedure involved careful dissection of the sylvian fissure, identification of the anterior communicating artery complex, and successful application of a titanium clip across the neck of the aneurysm, effectively isolating it from circulation while preserving flow through the parent vessels. Intraoperative angiography confirmed complete obliteration of the aneurysm with patency of surrounding vasculature. The procedure was completed without complications, with minimal blood loss and stable hemodynamics. After thorough evaluation and consultation with the neurosurgery team, the patient was scheduled for surgical clipping of the anterior communicating artery aneurysm. The procedure was deemed necessary due to the high rupture risk associated with ACOM aneurysms, particularly given the patient’s symptom presentation. The patient and her family were counselled regarding the risks, benefits, and alternatives to surgical intervention, after which informed consent was obtained.

A pterional craniotomy approach was utilized to access the aneurysm. The procedure involved careful dissection of the sylvian fissure, identification of the anterior communicating artery complex, and successful application of a titanium clip across the neck of the aneurysm, effectively isolating it from circulation while preserving flow through the parent vessels. Intraoperative angiography confirmed complete obliteration of the aneurysm with patency of surrounding vasculature. The procedure was completed without complications, with minimal blood loss and stable hemodynamics throughout.

Postoperatively, the patient was transferred to the neurosurgical intensive care unit for close monitoring. She was maintained on a comprehensive medication regimen that included: Injection Ceftriaxone 1 gram intravenously every 12 hours for prophylactic antimicrobial coverage; Injection Pantoprazole 40 mg intravenously once daily for gastric protection; Nimodipine 60 mg orally every 4 hours to prevent cerebral vasospasm; Injection Phenytoin 100 mg intravenously every 8 hours for seizure prophylaxis; Injection Diclofenac 75 mg intravenously as needed for pain management; and Injection Mannitol 100 ml intravenously every 6 hours to control intracranial pressure.

The patient initially exhibited mild postoperative drowsiness that gradually improved over the first 24 hours. Serial neurological examinations showed no focal deficits, with the patient regaining full orientation by postoperative day 2. Postoperative imaging on day 3 confirmed satisfactory clip placement with no evidence of cerebral ischemia or hemorrhage. Vital signs remained stable throughout the postoperative period, with blood pressure maintained within target range to prevent both hypoperfusion and hypertensive complications.

Comprehensive nursing care was integral to the patient’s recovery and involved multiple dimensions of specialized care. The nursing team implemented rigorous vital signs monitoring, with hourly checks of blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation during the first 48 hours, transitioning to every 2 hours as the patient stabilized. Meticulous neurological assessments were performed every 2 hours using the Glasgow Coma Scale, along with pupillary response, limb strength, and cranial nerve function evaluations to detect any early signs of neurological deterioration or vasospasm.

Pain management was carefully coordinated, with regular pain assessments using a numerical rating scale. Injection Diclofenac was administered as needed, with breakthrough pain managed according to established protocols. Preventive measures for common complications included early mobilization to prevent deep vein thrombosis, elevation of the head of bed to 30 degrees to optimize cerebral venous drainage, strict aseptic technique during wound care and intravenous line management to prevent infection, and careful fluid balance monitoring to prevent hypovolemia or fluid overload.

The nursing team maintained cerebral perfusion through strict adherence to blood pressure parameters (systolic blood pressure maintained between 120-140 mmHg), administered medications with precision timing, particularly nimodipine for vasospasm prophylaxis, and monitored for adverse medication effects such as hypotension or liver function abnormalities. Additionally, they provided crucial emotional support to the patient and family members through clear communication about the recovery process, involvement in care planning, and reassurance during anxiety.

A structured follow-up plan was implemented, and the patient was reviewed at 1-month and 3-month intervals postoperatively in the neurosurgical outpatient department. At 1-month follow-up, the patient reported mild fatigue but was otherwise functioning well. At the 3-month follow-up, the patient had resumed her household responsibilities and reported improved psychological well-being. A repeat CT angiogram confirmed stable clip placement with no residual aneurysm or new vascular pathology. Her mRS remained at 1, and the Barthel Index had improved to 100, indicating full independence in daily living. patient’s prognosis remained favorable with a high quality of life, and she was counseled about the importance of long-term follow-up and early reporting of any neurological symptoms.

Discussion

Possible ischemia to basal forebrain or orbitofrontal cortex, so few patients with a specific type of brain damage, which typically accounts for significant moments of momentary or behaviourally spontaneous confabulation, confabulate past the confusional stage. This holds for traumatic brain injury, diencephalic tumours, ruptured aneurysms, and alcoholic Korsakoff syndrome. Surprisingly, only a tiny percentage of these individuals later exhibit behaviourally spontaneous confabulation. Additionally, most people with this illness eventually cease making up stories and acquire a proper understanding of reality.⁸

It appears that the structures necessary for thought to adjust to reality fail, which explains behaviorally spontaneous confabulation. A major global cause of mortality and disability is stroke. A significant cause of hemorrhagic stroke, aneurysmal subarachnoid haemorrhage (aSAH), continues to have a dismal prognosis. The best results come from early diagnosis and therapy. Multiple comorbidities are frequently present in individuals with subarachnoid haemorrhage (S.A.H.) and acute subarachnoid haemorrhage (aSAH), complicating anaesthesia management.⁹

Selecting between A1-dominant and non-dominant hemisphere surgical techniques can be done using a straightforward categorisation approach that splits two categories of anterior communicating artery aneurysms.

The first variety of anteriorly or inferiorly projecting haemorrhage patterns is restricted to the basal subarachnoid space or the opposing inferior frontal lobe and gyrus rectus, extends below the plane of ascending A2 vessels, and frequently adheres to the top of the visual system (as seen on lateral view). Early imaging of the contralateral A1 presents more of a challenge because of the inferior projection of this kind of aneurysm. Approaching this type of aneurysm from the side of the dominant A1 is almost usually preferred to prevent problems.¹⁰

Those that extend superiorly or posteriorly between or behind the two A2 arteries fall into the second category. It can be challenging to see such small aneurysms due to the surrounding A2 vessels, especially when viewed from the side.¹¹

Our observations show that this lesion is the saccular anterior circulation aneurysm location that is missed the most frequently on a first arteriogram of fair grade. In unclear situations, further angiography, minutely precise oblique and enlarged images, and Finding the troublesome lesion could need 3D modelling of the communication zone with and without cross-compression of the opposing internal carotid artery. Gyrus rectus is among them. This aneurysm penetrates the interhemispheric fissure when the frontal lobe is initially elevated. This makes a surgical approach from the side of the dominant A1 less advantageous because it is straightforward to take proximal control of both A1 arteries before the commencement of aneurysm dissection.

Conclusion

Using the data from our analysis, we conclude that aneurysms more prominent than 4 mm, those with irregular or multilobulated walls, and those that are posteriorly or inferiorly oriented are all significantly related to an elevated risk of Intraoperative Rupture (I.O.R). There is a decreased risk of I.O.R. and a better outcome with temporary clipping of both A1 and Acomm aneurysms. By understanding the numerous risk factors that lead to I.O.R., the surgeon can anticipate it and be better equipped to handle it, even though the incidence of I.O.R. may never be eradicated. Because I.O.R. has a terrible prognosis, we should be very kind while managing aneurysms to prevent rupture. Additionally, a better approach in the surgical decision-making process may be possible with a more thorough understanding of the factors linked to the I.O.R. of the ACOMM aneurysm.

Consent

Written informed consent for publication of clinical details was obtained from the patient’s husband as the patient was experiencing significant cognitive impairment during the pre and post-operative recovery period following the neurosurgical intervention. The patient exhibited fluctuating levels of consciousness and difficulty with complex decision-making capacity as a result of temporary neurological effects following the clipping procedure for the anterior communicating artery aneurysm. The patient’s husband, as her legally recognized next of kin, provided surrogate consent after being thoroughly informed about the purpose, potential benefits, and risks of case publication. This consent process was documented in the patient’s medical record and was conducted in accordance with our institution’s ethics protocol. The consent was verified and countersigned by the attending physician to ensure ethical compliance.