# Management of Distal Anterior Cerebral Artery Aneurysms in a Tertiary Center in Pakistan: A Retrospective Analysis of Treatment Modalities and Angiographic and Short-Term Functional Outcomes

## TL;DR

This study examines the treatment and outcomes of rare brain aneurysms in Pakistan, showing successful results despite limited resources.

## Contribution

The study provides insights into managing distal ACA aneurysms in a low-resource setting with high success rates.

## Key findings

- Microsurgical clipping achieved 97.7% complete aneurysm occlusion.
- Endovascular coiling achieved 100% complete aneurysm occlusion.
- 89.8% of patients were functionally independent at 30-day follow-up.

## Abstract

Background

Distal anterior cerebral artery (dACA) aneurysms are an uncommon subset of intracranial aneurysms and pose unique anatomical and technical challenges due to their deep midline location and complex vascular anatomy. While management outcomes are well described in high-resource settings, data from low- and middle-income countries (LMICs) remain limited, particularly in the context of treatment delays and resource-driven decision-making.

Objective

The objective of the study is to describe the treatment pathways, immediate angiographic occlusion rates, periprocedural complications, and short-term functional outcomes of dACA aneurysms managed with microsurgical clipping or endovascular coiling at a tertiary care center in Pakistan.

Methods

This single-center retrospective descriptive study included consecutive patients with radiologically confirmed saccular dACA aneurysms (A2-A5 segments) treated between January 2023 and July 2025. Patients underwent microsurgical clipping or endovascular coiling based on institutional practice pathways and clinical judgment. Angiographic outcomes were assessed using postoperative imaging, with Raymond-Roy classification applied for coiled aneurysms. Functional outcomes were evaluated using the modified Rankin Scale (mRS) at discharge and at the 30-day follow-up.

Results

A total of 49 patients were included, with a mean age of 47 years; 29 patients (59.1%) were female, and 47 patients (96%) presented with ruptured aneurysms. Microsurgical clipping was performed in 43 patients (87.8%), while six patients (12.2%) underwent endovascular coiling. The mean interval from diagnosis to definitive treatment was 18.2 ± 2.9 days, with no documented rebleeding prior to intervention. Complete aneurysm occlusion was achieved in 42 of 43 clipped aneurysms (97.7%) and in six of six coiled aneurysms (100%). At the 30-day follow-up, 44 patients (89.8%) were functionally independent (mRS 0-2), with no mortality reported.

Conclusion

In a resource-limited setting with significant treatment delays, definitive management of dACA aneurysms using microsurgical clipping or selective endovascular coiling achieved excellent immediate angiographic results and favorable short-term functional outcomes. These findings demonstrate the feasibility of managing this complex pathology within systemic constraints when treatment strategies are tailored to institutional capabilities.