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Background and purpose: Endovascular coil embolization is an acceptable first-line treatment modality for ruptured anterior communicating artery (AcoA) aneurysms. The management varies among institutions because the causes for selection of coil embolization include not only aneurysm morphology but also institutional factors. We assess our experience with a "coil first" policy and determine predictors of complications. In addition, we report our institutional factors. Materials and methods: We retrospectively analyzed 27 consecutive patients with a ruptured AcoA aneurysm who underwent coil embolization at our institution between August 2013 and July 2016. During this period, none of the patients had a crossover to clipping. More than half of the neurosurgeons at our institution had much more experience with coils than with clips.Results: Of the patients, 11 were women (40.7%). The mean age of the patients was 58.0 years. The overall clinical outcome was modified Rankin scale (mRS) score of 0-2 in 16 patients (59.3%), 3 or 4 in 4 (14.8%), and 5 or 6 in 7 (25.9%). Intraprocedural rupture (IPR) occurred in 4 patients whose aspect ratios (ARs) were <1.5. Of the 4 patients, 1 had a small basal outpouching (SBO) associated with IPR.Delayed rebleeding occurred 3 years after the initial coil embolization. Three patients underwent additional treatment without procedure-related complications. One of the recurrent aneurysms with a SBO was treated with clipping in the chronic stage.Conclusion: As worse outcomes are associated with IPR and delayed rebleeding, crossover to clipping in the case of AR of <1.5 or SBO may allow a safer obliteration in the acute stage. Intentional partial coil embolization followed with additional clipping in the chronic stage, however, may improve procedural safety.

An 84-year-old woman visited our hospital with gastrointestinal bleeding and was hospitalized for suspected colon cancer by abdominal CT. She had a history of atrial fibrillation and she had undergone aortic valve replacement. Warfarin was stopped because PT-INR was excessively prolonged. On the third day of hospitalization, she developed unconsciousness and left hemiplegia, and Magnetic resonance (MR) showed ischemia in the right putamen and corona radiata on diffusion-weighted imaging. MR angiography revealed occlusion of the right middle cerebral artery. T 2weighted imaging showed no susceptibility vessel sign (SVS). She underwent endovascular thrombectomy. As a result, complete recanalization was achieved and white thrombus was retrieved. The pathological diagnosis of the retrieved white thrombus proved that the clump was gram-positive cocci. The pathological examination disclosed the final diagnosis of the embolic stroke due to infective endocarditis, but not atrial fibrillation or malignancy. It is important to predict the characteristics of thrombus from SVS, and if white thrombus is collected, it need to be submitted for pathology.

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