Multidimensional Comparison of Microsurgical Clipping and Endovascular Techniques for Anterior Communicating Artery Aneurysms: Balancing Occlusion Rates and Periprocedural Risks

<i>Background and Objectives</i>: The anterior communicating artery is a common location for intracranial aneurysms. Anterior communicating artery aneurysms (AcomA) pose a significant risk of rupture. Treatment options include microsurgical clipping and endovascular techniques, but the optimal approach remains controversial. This study aims to compare the outcomes of these two treatment modalities in a single-center patient cohort using a comprehensive matching process based on clinical and morphological parameters. <i>Materials and Methods</i>: A retrospective analysis was conducted on 1026 patients with 1496 intracranial aneurysms treated between 2000 and 2018. After excluding cases lacking 3D angiography or aneurysms in other locations or without treatment, 140 AcomA were selected. The study matched 24 surgically treated AcomA cases with 116 endovascularly treated cases based on 21 morphological and clinical criteria, including age, sex, Hunt and Hess score, and Fisher grade. <i>Results</i>: The microsurgical clipping group demonstrated a significantly higher rate of complete aneurysm occlusion compared to the endovascular group (<i>p</i> = 0.007). However, this was associated with a higher incidence of postoperative ischemic complications in the surgical group (13 out of 24 cases) compared to the endovascular group (2 out of 116 cases). Despite these complications, no significant differences were found in clinical outcomes at discharge or follow-up, as measured by the modified Rankin Scale (<i>p</i> > 0.999). Both groups had comparable rates of hydrocephalus, vasospasm, and delayed cerebral ischemia. <i>Conclusions</i>: Microsurgical clipping resulted in higher aneurysm occlusion rates but carried an increased risk of ischemic complications compared to endovascular treatment. Clinical outcomes were comparable between the two modalities, suggesting that treatment decisions should be individualized based on aneurysm characteristics and patient factors. Further prospective studies are warranted to optimize treatment strategies for AcomA.