4mm Acom artery unruptured aneurysm - must make decision on treatment options

Hi everyone,

I was recently diagnosed with an anterior communicating artery aneurysm as an incidental finding after an A&E visit. This is my timeline so far: fyi I’m in London, England

16th April: A&E visit after neurological symptoms (difficulty communicating, weak arm, numbness on one side of face, headache).

17th April: seen in TIA clinic. Tests included MRI. Neurologist suggested symptoms were caused by hemiplegic migraine with aura.

18th April: review of MRI showed possible aneurysm

23rd April: MRA scan to take closer look at vessels.

15th May: 4.5mm ACOM artery aneurysm confirmed. Referral to St George’s for discussion of my case at multidisciplinary meeting.

28th May: I had an appointment today with a neuro interventionist. He has said size is more like 3.3mm. He has provided treatment options. I can decide between coiling and clipping. There are pros and cons to each procedure and I am struggling to make a decision. The coiling is less invasive, requires less recovery time, but may require additional treatment following initial procedure. Clipping is invasive, carries risks of seizures and requires longer recovery, but is a permenant fix and is well established with studies confirming success over a long time period. Risk of rupture is present in both, as is risk of stroke. How do I make this decision??

Welcome again Daniela! Thank you for the update! I don’t know how one goes about which type of procedure to do as I wasn’t afforded a choice and left it all in the hands of my very capable Neurosurgeon. I have had three more repairs since I ruptured, the last being in 2020 with a stent. I have (had) an unusual shaped aneurysm called a multi lobed aneurysm which produced a lot of daughter sacs.

I do know there are serious risks with both procedures, starting with the anesthesia. I do believe that craniotomies are referred to as invasive because the surgeon removes part of the skull and then has to get to the aneurysm through the brain, so there’s a risk of infection and some other things as you’ve listed. With the endovascular method, a catheter is sent up an artery around the heart and into the brain, it’s referred to as a non invasive procedure but I rather prefer how you refer to it, less invasive.

Perhaps start with making a pro and con list for each. Take a good hard look at your lifestyle, hobbies, health and add those in as well. In all honesty, I roll my eyes when a surgeon gives us lay people a choice. How are we supposed to know what to do? I will ask a surgeon what would they recommend for their loved one? How many procedures of the two methods have they performed, which are they more comfortable doing?

I am curious as to why your team didn’t suggest an angiogram to see what’s going on. Many of our members, not all, get one before the surgeon gives a choice. I do hope members who were offered a choice will come and share the way they decided which method to take with you.

Hi Moltroub, thank you for your message and your suggestion to make a list of pros & cons. I think ultimately this will help a lot in the decision making process. I quite wish that the decision wasn’t resting with me. I keep changing my mind after reading cases/ studies. There are risks with both procedures, then you can delve deeper and compare risks for your artery/ aneurysm/ size/ risk factors etc etc. I feel I’ll never make a decision at this rate :-(.

I think you’re on the right track in researching studies. The internet can be a scary place for us. Try to stay with research that’s no older than five years as neurosurgery has advanced dramatically since I ruptured. Fortunately for me, medical science only took about seven years for them to develop a stent for mine. Also make sure that any article or research paper you’re reading can cite their sources and their sources are correct. There’s a very popular set of statistics out there that has no empirical evidence to support their statistics.

I know for me, my neurosurgeon didn’t think I was a good candidate for a craniotomy but the possibility was there for procedure #3 so I cut my hair rather short and we updated our wills. I didn’t have to have one, she used a balloon assist. Apparently people with multi lobed aneurysms don’t have a high rate of survival and thus they aren’t studied as much. My Neurosurgeon actually presented a paper at some big convention on them the weekend after I ruptured, came back to North Carolina and had another patient with a multi lobed aneurysm that ruptured. She had me promise to stay off the internet for a year after I ruptured and just ask her any questions. I’m really glad I kept that promise. She has also allowed me to ask questions that members have had here and I couldn’t find an answer to. I don’t see her a lot anymore and Atrium Health has messed up the way I used to send questions through my portal when the hospital was just Wake Forest Baptist Health so I stopped asking questions.

When do you see your surgeon again?

The internet is very scary. I have been feeling really anxious and low after reading so much literature around what could happen. It sounds like you have been through a lot, Moltroub. I am really happy for you that you found a wonderful surgeon who gave you good guidance. You must have been so scared at the time. I have an appointment to meet with a neurosurgeon on Tuesday. This time through my BUPA health cover. Hopefully I will make a decision after this appointment.

I had no affect (zero emotions) for several years after I ruptured, so not scared at all! There’s a positive in everything. I was able to eventually grieve for the loss of our Lab who saved me and my parents demise but differently than I used to grieve.

I’m very interested in what your next doctor will suggest, please keep in touch!

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Replying to Dani224. I have been a member of this group for a while, but have never contributed any of my story. I do enjoy reading about others experiences, and have found it very helpful. My unruptured aneurysm was discovered in 2022. It was 8x7x11 mm and on the Posterior Communicating Artery. I have another small one that is just being monitored currently. My neurosurgeon gave me the same choices as Dani224 and would not recommend coiling over clipping or vice versa. He did suggest an angiogram which would tell him exactly what we were dealing with. However my reasoning was that coiling would be much less invasive, and since it would be done by angiogram why have 2? In other words a procedure to determine how to proceed, and then another one to deal with the situation. The Neurosurgeon seemed to agree that that was a reasonable approach, and said he would just back out if it was not suitable for coiling at that point. As it turned out my aneurysm had daughter sacs, which he was able to coil, but the aneurysm had a wide neck and he was concerned that the coils wouldn’t be secure and so he backed out without coiling the main part. It was also located on an intersection between arteries and so clipping would have to be careful not to close off the artery behind. So I had to have a craniotomy a few months later. Despite having focal seizures after the craniotomy, which resolved themselves after a day or two, and of course being terrified going into the procedure, that aneurysm has now completely resolved according to my last MRI and no further action will be required regarding it. I wish you the best in making your decision.
Any questions please ask.

Thank you for sharing your story! I think you’re only the third or fourth member that an aneurysm had daughter sacs, the others may have had one or two. Do you mind me asking how many yours had? My doc stopped counting at 24 to get on with repairing mine, it’s also at the bifurcation (splits off to another artery)

If we want to reply to a member’s story and yet start our own, just need to put the “@“ sign in front of their name. That way, they’ll get a notification so in your story which is fabulous by the way, just @Dani224 gets the job done!

Hi , dani, I’m with London hospital, queens , I have a 4mm mca on the watch , I’m getting scanned agin in 7 months , my consultant neurosurgeon is mr toma, I havnt been offered any surgery yet , what did u decide x

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@LGR thank you for sharing your story and the reasons behind your decision making. I’m so happy for you that your clipping procedure was a success and your aneurysm has resolved. As far as I’m aware my aneurysm does not have any of these daughter sacs.

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Hi @mason2024, nice to meet another Londoner on here :slight_smile: I was also offered the possibility of watching. I didn’t want to do this as my 5 year risk of rupture is higher than the risk of either procedure. I have decided to go with coiling now

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I had my appointment with the surgeon who would perform clipping. He advised against clipping in my situation. He has explained that my aneurysm formed due to differences in sizes of the two arteries connecting to the Acom. This has led to one receiving a greater blood flow volume. Due to this, he would need to access the aneurysm from the left ( I think) side. He has said this area of the brain is responsible for emotions and personality, and I would risk changes here which could be mild to severe. He did not recommend taking this risk. He has referred me back to St George’s and I will go ahead with the coiling.

Has anyone else had these different sized arteries. Is this associated with any other risks/ problems (didn’t think to ask this yesterday for some reason).

Interesting, I don’t remember another member being told their aneurysm formed because of different sized arteries. I thought they all started getting a bit smaller as it goes from the carotid to the various ones. Learned something new today, thank you!

Hopefully you can get a radial (wrist) entry rather than a femoral (groin). It’s something else I learned here from our members. My arteries are all tortuous (squiggly) but my last angiogram they used my radial for the first time and it was a very easy recovery for me. Please keep us updated!

I think mine will have to be clipped eventually, I don’t know if they can do any other proceedure for right mca xx

The Neurosurgeon didn’t know until he got in there. Hindsight is a wonderful thing, but I should have gone for the clipping.
The craniotomy was not as bad as I thought it was going to be, and other than monitoring my other small aneurysm, no further intervention will be required. Phew!
Best of luck with everything.

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VNnthey do other treatment for right mca x

How long was your stay in hospital after your clipping x

How small is your other anerysum x

Hi. Initially I was told it would be 5 days but due to totally unexpected (on my part) focal seizures it was 15 days. The seizures occurred right after the procedure. I was unconscious, and they only lasted a few hours but I guess in an abundance of caution they kept me for monitoring. I haven’t had any problems since.

It’s 2 mm.