Comparative outcomes of microsurgical and endovascular treatment for ruptured and unruptured anterior communicating artery aneurysms

Anterior communicating artery (AComA) aneurysms remain challenging because of their complex anatomy, rupture risk, and proximity to vital structures. This study compared the long-term durability, retreatment rates, complications, and outcomes of microsurgical clipping and endovascular treatment. This retrospective study included 313 patients (≥ 18 years) with ruptured or unruptured AComA aneurysms treated at a single center (2006-2024). Patients were categorized by treatment modality into two groups: (1) Microsurgical clipping and (2) Endovascular treatment. Primary outcomes included aneurysm occlusion status, retreatment, and functional recovery, measured by the Glasgow Outcome Scale and the modified Rankin Scale. Of the 313 patients, 166 (53.0%) underwent microsurgical clipping, and 147 (47.0%) received endovascular treatment. Complete occlusion was achieved in 98.2% of the microsurgical group compared to 38.1% in the endovascular group (p < 0.001). Retreatment was required for 15.6% of endovascular patients (excluding planned two-stage procedures), while no retreatments occurred for the microsurgical group (p < 0.001). There were no statistically significant differences in functional outcomes between treatment groups at discharge and follow-up. Mean aneurysm size was smaller for ruptured aneurysms (5.82 mm) than unruptured ones (6.80 mm; p = 0.020), and diabetes mellitus was more prevalent in the unruptured group (27.5% vs. 8.1%; p < 0.001). Microsurgical clipping provided significantly higher rates of complete occlusion and lower retreatment rates compared to endovascular coiling, with equivalent functional outcomes. These findings support the continued role of microsurgery for treating AComA aneurysms, particularly in patients requiring durable occlusion and less intensive long-term surveillance, although differences in rupture status between the treatment groups should be considered when interpreting these results.