Elsevier

World Neurosurgery

Volume 83, Issue 2, February 2015, Pages 211-218
World Neurosurgery

Peer-Review Report
Microsurgical Clipping for Recurrent Aneurysms After Initial Endovascular Coil Embolization

https://doi.org/10.1016/j.wneu.2014.08.013Get rights and content

Objective

Surgical treatment for recurrent lesions of embolized aneurysms is difficult and challenging for many neurosurgeons because intra-aneurysmal coil masses are sometimes scarred to the wall of the aneurysm or adherent to adjacent vital structures. To assess the efficacy and safety of surgical treatment without coil removal for recurrent aneurysms after previous coil embolization, we retrospectively studied clinical results, angiographic results, and complications in patients treated with additional microsurgical clipping.

Methods

From April 2003 to April 2013, 7 patients with recurrent previous embolized aneurysms underwent microsurgical treatment.

Results

This series included 1 man and 6 women receiving endovascular coiling as the first-line treatment. One patient's aneurysm was unruptured, whereas the other 6 were ruptured. The aneurysm locations were posterior communicating (n = 3), anterior communicating (n = 2), ophthalmic (n = 1), and posterior inferior cerebellar (n = 1). The initial sizes ranged from 3–11.5 mm in diameter (mean, 6.6 mm), and the aspect ratios were 1.2 to 3.4 (mean, 1.9). In these aneurysms, the initial coiling result was complete occlusion in 5 patients, and neck remnants in 2 patients. The mechanism underlying aneurysm recurrence was coil compaction in 3 aneurysms, aneurysm regrowth in 3 aneurysms, and fundal migration in 1 aneurysm. The median recurrence latency was 28.8 months (range, 0.7–115 months). Microsurgical clippings without coil removal were used in 6 patients; a parent artery occlusion under bypass protection was done in 1 case with a posterior inferior cerebellar aneurysm. Fenestrated clips in combination with another type of clip were successfully used for 4 of 6 patients who were treated with direct neck clipping. No postoperative morbidity was observed, and postoperative imaging studies revealed complete occlusion of the aneurysms in all cases. There were no recurrences of aneurysms during the follow-up period (mean, 44.7 months; range, 0.5–118 months).

Conclusions

The microsurgical clipping without coil removal for recurrent lesions of embolized aneurysms is effective and safe when it is technically feasible. The tandem clipping in combination with a fenestrated clip is a crucial method for direct neck clipping without coil removal for previously coiled recurrent aneurysms. For unclippable lesions, a parent artery occlusion under bypass protection should be taken into consideration.

Introduction

Endovascular treatment of intracranial aneurysms has been widely accepted as an established treatment for aneurysmal subarachnoid hemorrhage (SAH) 20, 24. Although the International Subarachnoid Aneurysm Trial (ISAT) data proved the initial clinical advantage of endovascular treatment of ruptured aneurysms, coil instability necessitating aneurysm retreatment remains a major shortcoming of endovascular treatment 23, 28. In patients in whom relevant aneurysm recurrences are documented on imaging follow-up, both endovascular and surgical techniques can be used.

To assess the efficacy and safety of surgical treatment for recurrent aneurysms after previous embolization, we retrospectively studied angiographic results, clinical results, and complications in patients treated with additional surgery.

Section snippets

Methods

From April 2003 to April 2013, patients with recurrent aneurysms after initial endovascular coil embolization, who were treated at our institution were included in this study. During this period, 274 patients underwent endovascular treatment for intracranial aneurysms as the first-line treatment, including 105 patients with SAH and ruptured aneurysms (38.3%). Our retreatment indication for recurrent aneurysm after endovascular coil embolization is 1) residually more than 30% of the original

Results

During the 10-year study period, 21 patients, or 7.7 % of the group, received endovascular treatment for cerebral aneurysms, and experienced relevant aneurysm recurrences. Eight of the 21 patients refused the treatment and were followed by imaging studies. Therefore, 13 patients required additional treatment. Six patients were treated with endovascular recoiling, and 7 patients were treated surgically. The surgical series included 1 man and 6 women. The mean age was 60.3 years (range, 45–68

Discussion

In the present study, we demonstrated that the microsurgical treatment without coil removal for recurrent aneurysms after initial endovascular coil embolization was an effective and safe modality. Six of 7 cases were successfully treated with microsurgical direct neck clipping. For 1 patient, who had an unclippable recurrent aneurysm, a PAO under extracranial-intracranial bypass protection was safely performed.

Conclusion

For recurrent aneurysms after initial endovascular coil embolizations that are not feasible for standard recoiling, the microsurgical clipping without coil extraction is recommended when possible, and this policy led to successful clinical results in our practice. The tandem clipping method, in combination with a fenestrated clip, is crucial for direct neck clipping without coil removal for previously coiled recurrent aneurysms.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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