Unruptured anterior communicating artery aneurysms surgery: preservation of an old-fashioned, but ever-precious craft

The anterior communicating artery (AComA) is a common site for intracranial aneurysms. Complex regional anatomy increases surgical risks, and endovascular treatment is increasingly favoured, despite long-term durability concerns. This study aims to reassess the role of open surgery by presenting a 20-year single-centre experience with microsurgical management of unruptured AComA aneurysms. We sought to evaluate surgical outcomes, assess complication rates, and compare them to a contemporary endovascular cohort, thereby exploring whether surgical clipping remains a valid option in selected patients. We retrospectively analysed 64 consecutive patients with unruptured AComA aneurysms treated via microsurgical clipping from 2004 to 2024. Aneurysm selection was based on multidisciplinary evaluation. Demographic, radiological, surgical, clinical, neuropsychological and outcome data were collected and analysed. Secondarily, results were compared with 74 endovascularly treated cases managed during the same period. Microsurgical clipping achieved complete occlusion in 94% of cases at 1-year follow-up. Postoperative complications, graded according to the Treatment-Disability-Neurology (TDN) grade, occurred in only 12% as a TDN > 1, namely requiring intervention or resulting in a new deficit. Compared to the endovascular group, the surgical cohort demonstrated a significantly lower persistent opacification rate (6% vs. 22%, p = 0.01), without differences in morbidity. Microsurgical clipping of unruptured AComA aneurysms remains a safe, durable treatment when applied to carefully selected patients and performed by experienced teams. Hence, safely-performed surgical treatment still represents the best long-term treatment option for highly selected cases. It is of paramount importance to share a hard-earned expertise to preserve an old-fashioned, but ever-precious craft.