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CTA analysis and assessment of morphological factors related to rupture in 413 posterior communicating artery aneurysms

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Abstract

Posterior communicating artery (PcomA) aneurysms are frequently encountered, but there are few publications on their morphology. A growing number of aneurysms are incidental findings, which makes evaluation of rupture risk important. Our goal was to identify morphological features and anatomical variants associated with PComA aneurysms and to assess parameters related to rupture. We studied CT angiographies of 391 consecutive patients treated between 2000 and 2014 at a single institution. We determined clinically important morphological parameters and performed univariate and multivariate analysis. There were a total of 413 PComA aneurysms: 258 (62%) were ruptured and 155 (38%) unruptured. Ruptured PComA aneurysms had the potential to cause severe bleeding with IVH and/or temporal ICH (n = 170, 66% of ruptured). The main types of PComA origin were classified as follows: (1) separate (32%), (2) side by side (21%) and (3) a joint neck with the aneurysm (6%). After the multivariate logistic regression, the morphological parameters related to PComA aneurysm rupture were an irregular aneurysm dome, neck diameter, and aspect ratio >1.5. The most marked morphological features of the PComA aneurysms were: saccular nature (99%), infero-posterior dome orientation (42%), infrequency of large or giant aneurysms (4%), narrow neck compared to the aneurysm size, PComA originating directly from the aneurysm neck or the dome (28%), and fetal or dominant PComA on the side of the aneurysm (35%). There were location-related parameters that were more strongly associated with PComA aneurysm rupture than aneurysm size: an irregular aneurysm dome, larger diameter of the aneurysm neck and aspect ratio >1.5.

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Acknowledgements

Onni Järvinen, MSc, PhD, the consulted data analyst.

Jussi Numminen, MD, PhD, the consulted neuroradiologist.

Petri Honkanen Foundation.

Helsinki University Hospital research funds (VTR).

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Authors and Affiliations

  1. Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Topeliuksenkatu 5, PL 266, 00029 HUS, Helsinki, Finland

    Justiina Huhtakangas, Martin Lehecka, Hanna Lehto, Behnam Rezai Jahromi, Mika Niemelä & Riku Kivisaari

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  1. Justiina Huhtakangas
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  2. Martin Lehecka
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  3. Hanna Lehto
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  4. Behnam Rezai Jahromi
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Corresponding author

Correspondence to Justiina Huhtakangas.

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Funding

This study has been supported by a personal grant from the Petri Honkanen Foundation to Dr. J. Huhtakangas. This foundation did not have any role in the study design or implementation. Dr. Huhtakangas also received funding from the Helsinki University Hospital Research Funds (VTR).

Conflict of interest

None.

Ethical aspects

The authors have followed good ethical research practice. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This is a retrospective, register-based study. For this type of study formal consent is not required.

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Comments

The authors present a thorough evaluation of the morphological characteristics of a large series of consecutive posterior communicating artery aneurysms treated at their institution over a 4-year period. Measurements of the morphology of the aneurysms were performed on preoperative CTA studies. The ruptured vs. unruptured status of the aneurysm at the time of treatment was used to correlate the morphology with risk of rupture.

The study design has inherent flaws. There is selection bias as the authors only evaluated treated aneurysms. Unruptured aneurysms that were followed in their institution were not included in the analysis, which might have introduced bias. In addition, the status of the aneurysm at the time of treatment is an arbitrary parameter to rate risk of rupture. Indeed, many aneurysms in the “low-risk” unruptured state may have represented higher risk lesions that happened to be discovered and treated before rupture. In addition, morphology is only a single parameter in a large range of other factors related to hemorrhage. The authors point out that hemodynamics is another factor that was not evaluated. Increasing data in the literature also identify inflammatory mechanisms involved in aneurysm rupture.

Despite the study design issues, it is a welcome addition to the cerebrovascular literature. Accounting for all factors related to aneurysm rupture would be very difficult, and defining morphological factors that may represent higher risk in a large series of aneurysms is important. In addition, as the authors state, true natural history studies of aneurysm rupture risk are almost impossible today.

Neurosurgeons who treat cerebral aneurysms are always confronted with the dilemma of how to decide which unruptured aneurysms need to be treated. The stakes are high as subarachnoid hemorrhage is associated with significant morbidity and mortality; however, treatment of aneurysms also poses a risk to the patient. The size of the aneurysm alone is not an effective determining parameter. Indeed, in this study 38% of ruptured PCOM aneurysms were small in size. Additional morphological factors associated with hemorrhage as identified in this study will be beneficial to aid neurosurgeons with this difficult question.

Kadir Erkmen, Christopher M. Loftus

PA, USA

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Huhtakangas, J., Lehecka, M., Lehto, H. et al. CTA analysis and assessment of morphological factors related to rupture in 413 posterior communicating artery aneurysms. Acta Neurochir 159, 1643–1652 (2017). https://doi.org/10.1007/s00701-017-3263-4

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