In what cases would one approach an anterior communicating (AComm) artery aneurysm from the left?
- In a dominant left A1, dome pointing to the right, another left-sided aneurysm, possibly a left-sided blood clot
- Anterior communicating artery aneurysms can be approached from either side.
- The right side is chosen in patients with symmetric A1 segments
- This policy avoids the speech-dominant hemisphere in patients with balanced anatomy
- The side of the dominant A1 segment is chosen in patients with asymmetric A1 segments.
- Exploits advantages of A1 dominance:
- Early proximal control,
- Dome avoidance,
- Favourable view of the neck.
- Although infrequent in the general population (around 10%), unilateral A1 dominance is frequently seen in the aneurysm population (as high as 80%).
- Intraparenchymal hematomas associated with rupture are typically in the contralateral frontal lobe, but are contiguous with the aneurysm dome and easily evacuated after clipping.
- The side of approach may be influenced by the presence of other lateral aneurysms that might be treated simultaneously.
A standard pterional craniotomy is sufficient for most ACoA aneurysms, but the orbitozygomatic approach increases exposure for large, giant, and complex aneurysms (16% in the author’s experience).
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