Original Research| Volume 110, P74-79, April 2023

Risk factors for the rupture of anterior communicating artery aneurysms: Coexistence of fetal-type posterior cerebral artery and A1 segment hypoplasia/agenesis


      • The coexistence of ACA A1 segment agenesis/hypoplasia and fPCA increased aneurysm rupture in patients with AComA aneurysms.
      • The size of AComA aneurysms alone is not a guide for rupture.
      • Circle of Willis variations should be evaluated in detail in order to decide on treatment in AcomA aneurysms.



      To investigate the effect of the coexistence of fetal-type posterior communicating artery (fPCA) and anterior cerebral artery (ACA) A1 segment agenesis/hypoplasia on the rupture of an anterior communicating artery (AComA) aneurysm.

      Materials and Methods

      A total of 216 patients consecutively presenting with AComA aneurysms between January 2014 and December 2021 on digital subtraction angiography were evaluated. Patients without three-dimensional rotational angiography images, those aged under 18 years, those with suspected mycotic aneurysms, and those with dissecting and giant aneurysms were excluded from the study. The aneurysms were divided into two groups as ruptured and non-ruptured. Hemodynamic filling patterns were classified into four different types.


      The study included 192 AComA aneurysms, 44.8% (n = 86) ruptured and 55.2% (n = 106) non-ruptured. According to hemodynamic filling patterns, in type 1, the frequency of non-ruptured aneurysms was statistically significantly higher than that of ruptured aneurysms (39.5% vs 18.9%; p = 0.001). In type 4, where fPCA and ACA A1 segment agenesis/hypoplasia coexists, the frequency of ruptured aneurysms was significantly higher than that of non-ruptured aneurysms (10.5% vs 22.7%; p = 0.026). The most common aneurysm size range was 4–7 mm (n = 85; 44.3%). There was no statistically significant difference in size between the ruptured and non-ruptured aneurysms (p = 0.627).


      According to the hemodynamic filling classification, we observed that the presence of type 4 filling pattern, i.e., the coexistence of ACA A1 segment agenesis/hypoplasia and fPCA, increased the risk of rupture in AComA aneurysms.


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        • Dorcas H.P.
        The development of the cranial arteries in the human embryo.
        Contrib. Embryol., Washington1948: 205-261
        • Alpers B.J.
        • Berry R.G.
        Circle of Willis in cerebral vascular disorders.
        Arch Neurol. 1963; 8: 398
        • Karazincir S.
        • Ada E.
        • Sarılmaz A.
        • Yalçın Ö.
        • Vidinli B.
        • Şahin E.
        İntrakranyal Anevrizmalara Eşlik Eden Vasküler Varyasyon Ve Anomalilerin Sıklığı.
        Tanısal ve Girişimsel Radyoloji. 2004; 10: 103-109
        • Leyon J.J.
        • Kaliaperumal C.
        • Choudhari K.A.
        Aneurysm at the fenestrated anterior cerebral artery: Surgical anatomy and management.
        Clin Neurol Neurosurg. 2008; 110: 511-513
        • de Oliveira J.G.
        • du Mesnil de Rochemont R.
        • Beck J.
        • Hermann E.
        • Gerlach R.
        • Raabe A.
        • et al.
        A rare anomaly of the anterior communicating artery complex hidden by a large broad-neck aneurysm and disclosed by three-dimensional rotational angiography.
        Acta Neurochir (Wien). 2008; 150: 279-284
        • Kayembe K.N.
        • Sasahara M.
        • Hazama F.
        Cerebral aneurysms and variations in the circle of Willis.
        Stroke. 1984; 15: 846-850
        • de Gast A.N.
        • van Rooij W.J.
        • Sluzewski M.
        Fenestrations of the anterior communicating artery: incidence on 3D angiography and relationship to aneurysms.
        Am J Neuroradiol. 2008; 29: 296-298
        • Nathal E.
        • Yasui N.
        • Sampei T.
        • Suzuki A.
        Intraoperative anatomical studies in patients with aneurysms of the anterior communicating artery complex.
        J Neurosurg. 1992; 76: 629-634
      1. Lambert SL, Williams FJ, Oganisyan ZZ, Branch LA, Mader EC. Fetal-type variants of the posterior cerebral artery and concurrent infarction in the major arterial territories of the cerebral hemisphere. J Invest Med High Impact Case Reports 2016;4:232470961666540.

        • Arjal R.K.
        • Zhu T.
        • Zhou Y.
        The study of fetal-type posterior cerebral circulation on multislice CT angiography and its influence on cerebral ischemic strokes.
        Clin Imaging. 2014; 38: 221-225
        • Diogo M.C.
        • Fragata I.
        • Dias S.P.
        • Nunes J.
        • Pamplona J.
        • Reis J.
        Low prevalence of fetal-type posterior cerebral artery in patients with basilar tip aneurysms.
        J Neurointerv Surg. 2017; 9: 698-701
        • Kolukısa M.
        • Gürsoy A.E.
        • Kocaman G.
        • Dürüyen H.
        • Toprak H.
        • Asil T.
        Carotid endarterectomy in a patient with posterior cerebral artery infarction: influence of fetal type PCA on atypical clinical course.
        Case Rep Neurol Med. 2015; 2015: 1-3
        • Lee H.J.
        • Choi J.H.
        • Shin Y.S.
        • Lee K.S.
        • Kim B.S.
        Risk factors for the recurrence of posterior communicating artery aneurysm: the significance of fetal-type posterior cerebral artery.
        J Stroke Cerebrovasc Dis. 2021; 30
        • Xu Z.
        • Kim B.S.
        • Lee K.S.
        • Choi J.H.
        • Shin Y.S.
        Morphological and clinical risk factors for the rupture of posterior communicating artery aneurysms: significance of fetal-type posterior cerebral artery.
        Neurol Sci. 2019; 40: 2377-2382
        • Zhang Y.
        • Jing L.
        • Liu J.
        • Li C.
        • Fan J.
        • Wang S.
        • et al.
        Clinical, morphological, and hemodynamic independent characteristic factors for rupture of posterior communicating artery aneurysms.
        J Neurointerv Surg. 2016; 8: 808-812
        • Saeki N.
        • Rhoton A.L.
        Microsurgical anatomy of the upper basilar artery and the posterior circle of Willis.
        J Neurosurg. 1977; 46: 563-578
        • Chen S.
        • Li C.
        • Karmonik C.
        • Cheng Y.
        • Lv N.
        Performance of rupture-related morphological parameters in posterior communicating artery aneurysms with fetal-type variant.
        Folia Morphol (Warsz). 2021;
        • Dimmick S.J.
        • Faulder K.C.
        Normal variants of the cerebral circulation at multidetector CT angiography.
        Radiographics. 2009; 29: 1027-1043
        • Ujiie H.
        • Liepsch D.W.
        • Goetz M.
        • Yamaguchi R.
        • Yonetani H.
        • Takakura K.
        Hemodynamic study of the anterior communicating artery.
        Stroke. 1996; 27: 2086-2094
        • Vanderark G.D.
        • Kempe L.C.
        Classification of anterior communicating aneurysms as a basis for surgical approach.
        J Neurosurg. 1970; 32: 300-303
        • Microneurosurgery Y.MG.
        Clinical considerations, surgery of the intracranial aneurysms and results (microsurgical anatomy of basal cisterns & vessels of brain).
        George Thieme Verlag/Thieme-Stratton, Inc., NewYork1984
        • Wilson G.
        • Riggs H.E.
        • Rupp C.
        The pathologic anatomy of ruptured cerebral aneurysms.
        J Neurosurg. 1954; 11: 128-134
        • Juvela S.
        • Poussa K.
        • Lehto H.
        • Porras M.
        Natural history of unruptured intracranial aneurysms.
        Stroke. 2013; 44: 2414-2421
        • Kassell N.F.
        • Torner J.C.
        • Haley E.C.
        • Jane J.A.
        • Adams H.P.
        • Kongable G.L.
        • et al.
        The International Cooperative Study on the timing of aneurysm surgery.
        J Neurosurg. 1990; 73: 18-36
        • Nader-Sepahi A.
        • Casimiro M.
        • Sen J.
        • Kitchen N.D.
        Is aspect ratio a reliable predictor of intracranial aneurysm rupture?.
        Neurosurgery. 2004; 54: 1343-1348
        • Rinkel G.J.E.
        Natural history, epidemiology and screening of unruptured intracranial aneurysms.
        Rev Neurol (Paris). 2008; 164: 781-786
        • Schievink W.I.
        • Piepgras D.G.
        • Wirth F.P.
        Rupture of previously documented small asymptomatic saccular intracranial aneurysms.
        J Neurosurg. 1992; 76: 1019-1024
        • Yang H.
        • Jiang H.
        • Ni W.
        • Leng B.
        • Bin X.
        • Chen G.
        • et al.
        Treatment strategy for unruptured intracranial aneurysm in elderly patients: coiling, clipping, or conservative?.
        Cell Transplant. 2019; 28: 767-774
      2. Baumann F, Khan N, Yonekawa Y. Patient and aneurysm characteristics in multiple intracranial aneurysms. Chang. Asp. Stroke Surg. Aneurysms, Dissections, Moyamoya Angiopathy EC-IC Bypass, Vienna: Springer Vienna; n.d., p. 19–28.

        • Li M.
        • Jiang Z.
        • Yu H.
        • Hong T.
        Size ratio: A morphological factor predictive of the rupture of cerebral aneurysm?.
        Can J Neurol Sci/J Can Des Sci Neurol. 2013; 40: 366-371
        • Juvela S.
        • Porras M.
        • Poussa K.
        Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture.
        J Neurosurg. 2000; 93: 379-387