Elsevier

World Neurosurgery

Volume 84, Issue 2, August 2015, Pages 246-253
World Neurosurgery

Original Article
Microsurgical Treatment of Previously Coiled Intracranial Aneurysms: Systematic Review of the Literature

https://doi.org/10.1016/j.wneu.2015.02.027Get rights and content

Objective

To assess indications, complications, clinical outcomes, and technical nuances of microsurgical treatment of previously coiled intracranial aneurysms.

Methods

A systematic review of the literature was performed using PubMed/MEDLINE and EMBASE databases from January 1990 to December 2013. English-language articles reporting on microsurgical treatment of previously coiled intracranial aneurysms were included. Articles that involved embolization materials other than coils were excluded. Data on aneurysm characteristics, indications for surgery, techniques, complications, angiographic obliteration rates, and clinical outcomes were collected.

Results

The literature review identified 29 articles reporting on microsurgical clipping of 375 previously coiled aneurysms. Of the aneurysms, 68% were small (<10 mm). Indications for clipping included the presence of a neck remnant (48%) and new aneurysmal growth (45%). Rebleeding before clipping was reported in 6% of cases. Coil extraction was performed in 13% of cases. The median time from initial coiling to clipping was 7 months. The angiographic cure rate was 93%, with morbidity and mortality of 9.8% and 3.6%, respectively.

Conclusions

Microsurgical clipping of previously coiled aneurysms can result in high obliteration rates with relatively low morbidity and mortality in select cases. Considerations for microsurgical strategies include the presence of sufficient aneurysmal tissue for clip placement and the potential need for temporary occlusion or flow arrest. Coil extraction is not needed in most cases.

Introduction

The endovascular treatment of intracranial aneurysms was first introduced by Serbinenko in 1974 (51) and has seen several major advancements since that time. As the widespread use of endovascular coiling continues to increase, so does the population of patients who require retreatment for incomplete occlusion or recurrence. The International Subarachnoid Aneurysm Trial (ISAT) reported a 34% combined rate of aneurysm subtotal occlusion and refilling after endovascular coiling (37). The Cerebral Aneurysm Rerupture After Treatment (CARAT) study reported annual retreatment rates of coiled aneurysms of 13.3%, 4.5%, and 1.1% during the first, second, and subsequent years (22). Although the natural history of previously coiled aneurysms with remnants and aneurysms demonstrating regrowth has not been fully elucidated 5, 22, 47, 55, significant residual aneurysm filling has been linked to hemorrhage and mass effect symptoms, particularly in previously ruptured aneurysms 6, 7, 49. Approximately one third of residual lesions show evidence of progressive growth, which may be an indication for retreatment 10, 19. At the present time, retreatment options for previously coiled intracranial aneurysms include repeat endovascular treatment, with or without adjunctive endovascular devices; microsurgical clipping; and parent artery occlusion. Revascularization techniques may be needed when occlusion of a parent artery is planned. The evidence for microsurgical retreatment of previously coiled intracranial aneurysms is sparse, and guidelines are lacking. We aimed to review systematically the English-language literature on this issue with a focus on indications, complications, outcomes, and technical nuances.

Section snippets

Materials and Methods

A search strategy was designed to identify relevant reports on microsurgical treatment of previously coiled intracranial aneurysms. The search was restricted to English-language articles published between January 1990 and December 2013. Articles were identified from PubMed/MEDLINE and EMBASE databases using the key terms “intracranial aneurysm,” “coil embolization,” “endovascular surgery,” “aneurysm recurrence,” and “surgical clipping.” Additional sources were identified from manual review of

Epidemiology

We identified 27 articles; 1 was excluded for exclusively using embolization material other than coils (26), and 1 was excluded for overlapping patient data that were updated in a more recent publication (27). After manual review of bibliographies, 4 additional studies were identified 2, 21, 32, 55. The 29 studies that were included are listed in Table 1 2, 3, 6, 7, 8, 11, 12, 16, 17, 18, 21, 24, 25, 27, 29, 30, 32, 36, 39, 42, 46, 49, 50, 52, 53, 54, 56, 59, 61. Table 2 summarizes data from

Discussion

As endovascular coil embolization for the treatment of intracranial aneurysms has become more prevalent, the number of intracranial aneurysms requiring retreatment has increased (56). Indications for retreatment include incomplete obliteration, subsequent growth of residual neck or dome, and coil compaction resulting in fundal refilling 10, 21, 52. Incomplete aneurysm treatment associated with coil embolization as well as aneurysm recurrence may necessitate subsequent microsurgical treatment

Conclusions

Although advances have occurred in the endovascular treatment of intracranial aneurysms, microsurgery remains an important technique for managing many aneurysms, including aneurysms for which endovascular treatment fails. A significant number of patients treated with endovascular coil embolization have incomplete occlusion, with some developing recanalization and growth of lesions warranting consideration of repeat treatment. Although current understanding of the natural history of neck

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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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