Top

Published in:

Open Access 01-03-2024 | Aneurysm | Anatomic Variations

The anterior communicating artery variants: a meta-analysis with a proposed classification system

Authors: George Triantafyllou, Răzvan Costin Tudose, Christos Tsiouris, George Tsakotos, Marios Loukas, R. Shane Tubbs, Theodosis Kalamatianos, Christos Chrissicopoulos, Katerina Al-Nasraoui, Christos Koutserimpas, Mugurel Constantin Rusu, Konstantinos Natsis, Anastasios Kotrotsios, Maria Piagkou

Published in: Surgical and Radiologic Anatomy | Issue 5/2024

Abstract

Morphological and morphometric variants of the anterior communicating artery (AComA) have been described by multiple studies; however, a complete classification system of all possible morphological variants with their prevalence is lacking. The current systematic review with meta-analysis combines data from different databases, concerning the AComA morphological and morphometric variants (length and diameter). Emphasis was given to the related clinical implications to highlight the clinical value of their knowledge. The typical AComA morphology occurs with a pooled prevalence (PP) of 67.3%, while the PP of atypical AComA is 32.7%. The identified AComA morphological variants (artery’s hypoplasia, absence, duplication, triplication, differed shape, fenestration, and the persistence of a median artery of the corpus callosum- MACC) were classified in order of frequency. The commonest presented variants were the AComA hypoplasia (8%) and the anterior cerebral artery (ACA) fusion (5.9%), and the rarest ones were the MACC persistence (2.3%), and the AComA triplication (0.7%). The knowledge of those variants is essential, especially for neurosurgeons operating in the area. Given the high prevalence of AComA aneurysms, an adequate and complete classification of those variants is of utmost importance.

Alfano JM, Kolega J, Natarajan SK, Xiang J, Paluch RA, Levy EI, Siddiqui AH, Meng H (2013) Intracranial aneurysms Occur more frequently at Bifurcation sites that typically experience higher hemodynamic stresses. Neurosurg 73:497–505. https://doi.org/10.1227/neu.0000000000000016CrossRef

Ardakani SK, Dadmehr M, Nejat F, Ansari S, Eftekhar B, Tajik P, El Khashab M, Yazdani S, Ghodsi M, Mahjoub F, Monajemzadeh M, Nazparvar B, Abdi-Rad A (2008) The cerebral arterial Circle (Circulus Arteriosus Cerebri). Pediatr Neurosurg 44:388–392. https://doi.org/10.1159/0001499061CrossRefPubMed

Blackburn IW (1907) Anomalies of the encephalic arteries among the insane. A study of the arteries at the base of the encephalon in two hundred and twenty consecutive cases of mental disease, with special reference to anomalies of the circle of Willis. J Comp Neurol Psychol 17:493–517. https://doi.org/10.1002/cne.920170604CrossRef

Blackburn IW (1910) On the median anterior cerebral artery as found among the insane. J Comp Neurol Psychol 20:185–194. https://doi.org/10.1002/cne.920200303CrossRef

Chen HW, Yen PS, Lee CC, Chen CC, Chang PY, Lee SK, Lee WH, Ling CM, Chou ASB (2004) Magnetic resonance angiographic evaluation of circle of Willis in the general population: a morphologic study in 507 cases. Chin J Radiol 29:223–229

Chuang Y-M, Chan L, Lai Y-J, Kuo K-H, Chiou Y-H, Huang L-W, Kwok Y-T, Lai T-H, Lee S-P, Wu H-M, Yeh Y-C (2013) Configuration of the Circle of Willis is associated with less symptomatic intracerebral hemorrhage in ischemic stroke patients treated with intravenous thrombolysis. J Crit Care 28:166–172. https://doi.org/10.1016/j.jcrc.2012.08.0181CrossRefPubMed

De Silva KD, Silva R, Gunasekera WSL, Jayesekera R (2009) Prevalence of typical circle of Willis and the variation in the anterior communicating artery: a study of a Sri Lankan population. Ann Indian Acad Neurol 12:157. https://doi.org/10.4103/0972-2327.563141CrossRefPubMedPubMedCentral

Deeks JJ, Higgins JP, Altmam DG (2019) Analysing data and undertaking meta-analyses. In: Cochrane Handbook for Systematic Reviews of Interventions pp. 241–284

Dhanalakshmi V, Satish Kumar S, Suresh Kumar T, Arun Kumar K (2019) Anterior communicating artery: a cadaveric study. Int J Anat Res 7:6261–6264. https://doi.org/10.16965/ijar.2018.4531CrossRef

10.

Dumitrescu AM, Eva L, Haba D, Cucu AI, Dumitrescu GF, Burduloi VM, Dima-Cozma LC, Vatavu R, Moroşanu GC, Sava A (2022) Anatomical study of circle of Willis on fresh autopsied brains. A study of a Romanian population. Rom J Morphol Embryol 63:395–406. https://doi.org/10.47162/rjme.63.2.101CrossRefPubMedPubMedCentral

11.

Eftekhar B, Dadmehr M, Ansari S, Ghodsi M, Nazparvar B, Ketabchi E (2006) Are the distributions of variations of circle of Willis different in different populations? – results of an anatomical study and review of literature. BMC Neurol 6. https://doi.org/10.1186/1471-2377-6-221

12.

Fawcett E, Blachford JV (1905) The Circle of Willis: an examination of 700 specimens. J Anat Physiol 40(1):632–670

13.

Feng L, Mao H-J, Zhang D-D, Zhu Y-C, Han F (2023) Anatomical variations in the Circle of Willis and the formation and rupture of intracranial aneurysms: a systematic review and meta-analysis. Front Neurol 13. https://doi.org/10.3389/fneur.2022.10989501

14.

Fredon F, Baudouin M, Hardy J, Kouirira A, Jamilloux L, Taïbi A, Mabit C, Valleix D, Rouchaud A, Durand-Fontanier S (2021) An MRI study of typical anatomical variants of the anterior communicating artery complex. Surg Radiol Anat 43:1983–1988. https://doi.org/10.1007/s00276-021-02782-xCrossRefPubMed

15.

Furuichi K, Ishikawa A, Uwabe C, Makishima H, Yamada S, Takakuwa T (2018) Variations of the Circle of Willis at the end of the human embryonic period. Anat Rec 301:1312–1319. https://doi.org/10.1002/ar.23794CrossRef

16.

Geetha G, Narayanan S (2021) A cadaveric study of anterior communicating artery. Nat J Clin Anat 10:75. https://doi.org/10.4103/njca.njca_71_201CrossRef

17.

Han A, Yoon DY, Chang SK, Lim KJ, Cho B-M, Shin YC, Kim SS, Kim KH (2011) Accuracy of CT angiography in the assessment of the circle of Willis: comparison of volume-rendered images and digital subtraction angiography. Acta Radiol 52:889–893. https://doi.org/10.1258/ar.2011.1102231CrossRefPubMed

18.

Hashemi SR, Mahmoodi R, Amirjamshidi A (2013) Variations in the anatomy of the Willis’ circle: a 3-year cross-sectional study from Iran (2006–2009). Are the distributions of variations of circle of Willis different in different populations? Result of an anatomical study and review of literature. Surg Neurol Int 4:65CrossRefPubMedPubMedCentral

19.

Hoksbergen AWJ, Fülesdi B, Legemate DA, Csiba L (2000) Collateral configuration of the Circle of Willis. Stroke 31:1346–1351. https://doi.org/10.1161/01.str.31.6.13461CrossRefPubMed

20.

Hostiuc S, Rusu MC, Negoi I, Dorobantu B, Grigoriu M (2019) Anatomical variants of renal veins: a meta-analysis of prevalence. Sci Rep 9:10802. https://doi.org/10.1038/s41598-019-47280-8CrossRefPubMedPubMedCentral

21.

Iqbal S (2013) A comprehensive study of the anatomical variations of the Circle of Willis in Adult Human brains. J Clin Diagn Res. https://doi.org/10.7860/jcdr/2013/6580.35631CrossRefPubMedPubMedCentral

22.

Jacquens A, Shotar E, Bombled C, Glémain B, Sourour N-A, Nouet A, Premat K, Lenck S, Degos V, Clarençon F (2020) Is anatomical variations a risk factor for cerebral vasospasm in Anterior communicating Complex aneurysms rupture? Stroke 51:998–1001. https://doi.org/10.1161/strokeaha.119.0266611CrossRefPubMed

23.

Jiménez-Sosa MS, Cantu-Gonzalez JR, Morales-Avalos R, de la Garza-Castro O, Quiroga-Garza A, Pinales-Razo R, Elizondo-Riojas G, Elizondo-Omaña RE, Guzmán- López S (2017) Anatomical variants of Anterior cerebral arterial Circle: a study by Multidetector computerized 3D Tomographic Angiography. Int J Morphol 35:1121–1128. https://doi.org/10.4067/s0717-950220170003000491CrossRef

24.

Jones JD, Castanho P, Bazira P, Sanders K (2020) Anatomical variations of the circle of Willis and their prevalence, with a focus on the posterior communicating artery: a literature review and meta-analysis. Clin Anat 34:978–990. https://doi.org/10.1002/ca.236621CrossRefPubMed

25.

Kamath S (1981) Observations on the length and diameter of vessels forming the circle of Willis. J Anat 133(Pt 3):419–423PubMedPubMedCentral

26.

Kapoor K, Singh B, Dewan LIJ (2008) Variations in the configuration of the circle of Willis. Anat Sci Int 83:96–106. https://doi.org/10.1111/j.1447-073x.2007.00216.x1CrossRefPubMed

27.

Karatas A, Yilmaz H, Coban G, Koker M, Uz A (2015) The anatomy of circulus arteriosus cerebri (circle of Willis): a study in Turkish population. Turk Neurosurg. https://doi.org/10.5137/1019-5149.jtn.13281-14.11CrossRefPubMed

28.

Kardile PB (2013) Anatomical variations of anterior communicating artery. J Clin Diagn Res Doi. https://doi.org/10.7860/jcdr/2013/6664.37251CrossRef

29.

Kaspera W, Ładziński P, Larysz P, Hebda A, Ptaszkiewicz K, Kopera M, Larysz D (2014) Morphological, Hemodynamic, and clinical independent risk factors for anterior communicating artery aneurysms. Stroke 45:2906–2911. https://doi.org/10.1161/strokeaha.114.0060551CrossRefPubMed

30.

Kayembe KN, Sasahara M, Hazama F (1984) Cerebral aneurysms and variations in the circle of Willis. Stroke 15:846–850. https://doi.org/10.1161/01.str.15.5.8461CrossRefPubMed

31.

Krabbe-Hartkamp MJ, van der Grond J, de Leeuw FE, de Groot JC, Algra A, Hillen B, Breteler MM, Mali WP (1998) Circle of Willis: morphologic variation on three-dimensional time-of-flight MR angiograms. Radiol 207:103–111. https://doi.org/10.1148/radiology.207.1.95303051CrossRef

32.

Krzyzewski RM, Tomaszewska IM, Lorenc N, Kochana M, Goncerz G, Klimek-Piotrowska W, Walocha K, Urbanik A (2014) Variations of the anterior communicating artery complex and occurrence of anterior communicating artery aneurysm: A2 segment consideration. Folia Med Cracov 54(1):13–20PubMed

33.

Krzyżewski RM, Tomaszewski KA, Kochana M, Kopeć M, Klimek-Piotrowska W, Walocha JA (2014) Anatomical variations of the anterior communicating artery complex: gender relationship. Surg Radiol Anat 37:81–86. https://doi.org/10.1007/s00276-014-1313-71CrossRefPubMedPubMedCentral

34.

Leipzig TJ, Morgan J, Horner TG, Payner T, Redelman K, Johnson CS (2005) Analysis of intraoperative rupture in the Surgical treatment of 1694 Saccular aneurysms. Neurosurgery 56:455–468. https://doi.org/10.1227/01.neu.0000154697.75300.c2CrossRefPubMed

35.

López-Sala P, Alberdi N, Mendigaña M, Bacaicoa M-C, Cabada T (2020) Anatomical variants of anterior communicating artery complex. A study by Computerized Tomographic Angiography. J Clin Neurosci 80:182–187. https://doi.org/10.1016/j.jocn.2020.08.0191CrossRefPubMed

36.

Menshawi K, Mohr JP, Gutierrez J (2015) A functional perspective on the Embryology and anatomy of the cerebral blood supply. J Stroke 17:144. https://doi.org/10.5853/jos.2015.17.2.1441CrossRefPubMedPubMedCentral

37.

Nyasa C, Mwakikunga A, Tembo LH, Dzamalala C, Ihunwo AO (2021) Anatomical variations and morphometric properties of the circulus arteriosus cerebri in a cadaveric Malawian population. Fol Morphol 80:820–826. https://doi.org/10.5603/fm.a2020.01421CrossRef

38.

Ogawa A, Suzuki M, Sakurai Y, Yoshimoto T (1990) Vascular anomalies associated with aneurysms of the anterior communicating artery: microsurgical observations. J Neurosurg 72:706–709. https://doi.org/10.3171/jns.1990.72.5.07061CrossRefPubMed

39.

Orakdogen M, Emon ST, Somay H, Engin T, Is M, Hakan T (2016) Vascular variations associated with intracranial aneurysms. Turk Neurosurg. https://doi.org/10.5137/1019-5149.jtn.17839-16.11CrossRefPubMed

40.

Ozaki T, Handa H, Tomimoto K, Hazama F (1977) Anatomical variations of the arterial system of the base of the brain. Arch Jap Chir 46:3–17

41.

Padget DH (1944) The circle of Willis: its embryology and anatomy. In: WE, Dandy (eds) Intracranial arterial aneurysms. Comstock Publishing Co, New York, pp 67–90

42.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71CrossRefPubMedPubMedCentral

43.

Papantchev V, Hristov S, Todorova D, Naydenov E, Paloff A, Nikolov D, Tschirkov A, Ovtscharoff W (2007) Some variations of the circle of Willis, important for cerebral protection in aortic surgery — a study in Eastern europeans. Eur J Cardiothorac Surg 31:982–989. https://doi.org/10.1016/j.ejcts.2007.03.0201CrossRefPubMed

44.

Papantchev V, Stoinova V, Aleksandrov A, Todorova-Papantcheva D, Hristov S, Petkov D, Nachev G, Ovtscharoff W (2013) The role of Willis circle variations during unilateral selective cerebral perfusion: a study of 500 circles. Eur J Cardiothorac Surg 44:743–753. https://doi.org/10.1093/ejcts/ezt1031CrossRefPubMed

45.

Puchades-Orts A, Nombela-Gomez M, Ortuño-Pacheco G (1976) Variation in form of circle of Willis: some anatomical and embryological considerations. Anat Rec 185:119–123. https://doi.org/10.1002/ar.10918501121CrossRefPubMed

46.

Ravikanth R, Philip B (2019) Magnetic resonance angiography determined variations in the circle of Willis: analysis of a large series from a single center. Tzu Chi Med J 31:52. https://doi.org/10.4103/tcmj.tcmj_167_171CrossRefPubMedCentral

47.

Raybaud C (2010) Normal and abnormal embryology and development of the intracranial vascular system. Neurosurg Clin N Am 21:399–426. https://doi.org/10.1016/j.nec.2010.03.0111CrossRefPubMed

48.

Rhoton AL (2002) The supratentorial arteries. Neurosurgery 51:S1–53. https://doi.org/10.1097/00006123-200210001-00003CrossRefPubMed

49.

Riveros A, Vega C, Negroni M, Villagrán F, Binvignat O, Olave E (2022) Variations of the cerebral arterial Circle. Morphological and clinical analysis. Int J Morphol 40:632–639. https://doi.org/10.4067/s0717-950220220003006321CrossRef

50.

Shatri J, Cerkezi S, Ademi V, Reci V, Bexheti S (2019) Anatomical variations and dimensions of arteries in the anterior part of the circle of Willis. Fol Morphol 78:259–266. https://doi.org/10.5603/fm.a2018.00951CrossRef

51.

Stehbens WE (1963) Aneurysms and anatomic variation of cerebral arteries. Arch Pathol 75:45–64PubMed

52.

Stojanovic N, Stefanovic I, Randjelovic S, Mitic R, Bosnjakovic P, Stojanov D (2009) Presence of anatomical variations of the circle of Willis in patients undergoing surgical treatment for ruptured intracranial aneurysms. Vojnosanit Pregl 66:711–717. https://doi.org/10.2298/vsp0909711s1CrossRefPubMed

53.

Suzuki M, Fujisawa H, Ishihara H, Yoneda H, Kato S, Ogawa A (2007) Side selection of pterional approach for anterior communicating artery aneurysms – surgical anatomy and strategy. Acta Neurochir 150:31–39. https://doi.org/10.1007/s00701-007-1466-9CrossRefPubMed

54.

Thenmozhi A, Kalpana R, Subadha C (2019) Anatomic variants of the anterior part of the cerebral arterial circle: a cadaveric study. Int J Anat Res 7:6516–6520. https://doi.org/10.16965/ijar.2019.1561CrossRef

55.

Tudose RC, Rusu MC, Hostiuc S (2023) The Vertebral Artery: A Systematic Review and a Meta-Analysis of the Current Literature. Diagnostics 13: 2036. https://doi.org/10.3390/diagnostics13122036

56.

Wijesinghe P, Steinbusch HWM, Shankar SK, Yasha TC, De Silva KRD (2020) Circle of Willis abnormalities and their clinical importance in ageing brains: a cadaveric anatomical and pathological study. J Chem Neuroanat 106:101772. https://doi.org/10.1016/j.jchemneu.2020.1017721CrossRefPubMed

57.

Windle BC (1888) The arteries forming the circle of Willis. J Anat Physiol 22(2):289PubMedPubMedCentral

58.

Żurada A, Gielecki J, Shane Tubbs R, Loukas M, Maksymowicz W, Chlebiej M, Cohen-Gadol AA, Zawiliński J, Nowak D, Michalak M (2011) Detailed 3D-morphometry of the anterior communicating artery: potential clinical and neurosurgical implications. Surg Radiol Anat 33:531–538. https://doi.org/10.1007/s00276-011-0792-z1CrossRefPubMed

59.

Uchino A (2022) Variations of the proximal anterior cerebral artery (ACA), including anterior communicating artery (ACoA). Atlas of the Supraaortic Craniocervical arterial variations. Springer, Singapore. https://doi.org/10.1007/978-981-16-6803-6_9CrossRef

60.

Schwarzer G, Carpenter JR, Rücker G (2015) Small-study effects in Meta-Analysis. Meta-analysis with R. Use R! Springer, Cham. https://doi.org/10.1007/978-3-319-21416-0_5CrossRef

61.

Viechtbauer W, Cheung MW-L (2010) Outlier and infuence diagnostics for meta-analysis. Res Synth Methods 1:112–125. https://doi.org/10.1002/jrsm.11CrossRefPubMed

62.

Fu R, Gartlehner G, Grant M, Shamliyan T, Sedrakyan A, Wilt TJ, Grifth L, Oremus M, Raina P, Ismaila A (2011) Conducting quantitative synthesis when comparing medical interventions: AHRQ and the efective health care program. J Clin Epidemiol 64(11):1187–1197CrossRefPubMed

63.

Balduzzi S, Rücker G, Schwarzer G (2019) How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health 22(4):153–160CrossRefPubMedPubMedCentral

64.

Harrer M, Cuijpers P, Furukawa TA, Ebert DD (2021) Doing Meta-Analysis with R: A Hands-On Guide. Boca Raton, FL and London: Chapman & Hall/CRC Press. ISBN 978-0-367-61007-4

65.

Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414): 557 – 60. https://doi.org/10.1136/bmj.327.7414.5

Title: The anterior communicating artery variants: a meta-analysis with a proposed classification system
Authors: George Triantafyllou
Răzvan Costin Tudose
Christos Tsiouris
George Tsakotos
Marios Loukas
R. Shane Tubbs
Theodosis Kalamatianos
Christos Chrissicopoulos
Katerina Al-Nasraoui
Christos Koutserimpas
Mugurel Constantin Rusu
Konstantinos Natsis
Anastasios Kotrotsios
Maria Piagkou
Publication date: 01-03-2024
Publisher: Springer Paris
Keywords: Aneurysm
Aneurysm
Published in: Surgical and Radiologic Anatomy / Issue 5/2024
Print ISSN: 0930-1038
Electronic ISSN: 1279-8517
DOI: https://doi.org/10.1007/s00276-024-03336-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The anterior communicating artery variants: a meta-analysis with a proposed classification system

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 5/2024

Endoscopic trans-eustachian tube approach: identifying the precise landmarks, a novel radiological and anatomical evaluation

Anatomy of the temporal region to guide filler injections

Measurements of oculo-palpebral landmarks and evaluation of patient’s head position

A cross-sectional survey on university students’ knowledge, attitudes, and behaviors regarding organ, tissue, and body donation

3D anatomy of the supraorbital and greater occipital nerve trajectories

Cone-beam computed tomography of accessory canals of the canalis sinuosus and analysis of the related risk factors