Premammillary artery infarction after microsurgical clipping of unruptured posterior communicating artery aneurysm: risk factors, surgical, and anatomical considerations

Abstract

Rationale: Posterior communicating artery (PCoA) aneurysm is common and sometimes requires microsurgery; however, as data on premammillary artery (PMA) infarction after clipping is scarce, we retrospectively reviewed cases of post-clipping PMA infarction to analyze incidence, independent risk factors of infarction, and anatomical considerations. Methods: Data from 569 consecutive patients who underwent microsurgical clipping for unruptured PCoA aneurysm between January 2008 and December 2020 were included. Patients were categorized into the normal or the PMA infarction group. Statistical analyses and comparisons between the two groups were used to determine the influence of various factors. Results: The normal group included 515 patients while the PMA infarction group had 31. The mean length of hospital stay was significantly longer in the PMA infarction group (10.3 ± 9.1 days) than in the normal group (6.5 ± 6.4 days; p < 0.0001). The distribution of Glasgow Outcome Scale (GOS) at discharge was significantly different between the two groups (p ≤ 0.0001) but was not so at 6 months after discharge (p = 0.0568). Multivariate-logistic-regression analysis identified aneurysm size (odds ratio [OR], 1.194; 95% confidence interval [CI], 1.08–1.32; p = 0.0005) and medial direction of aneurysm (OR, 4.615; 95% CI, 1.224–17.406; p = 0.0239) as independent risk factors of post-clipping PMA infarction. Conclusions: Surgeons must beware of PMA infarction after clipping of large aneurysms that are medial in direction. Intraoperative verification of the patency of the PCoA and the PMA from various angles using various intraoperative methods can reduce morbidity due to PMA infarction.