Elsevier

World Neurosurgery

Volume 92, August 2016, Pages 434-444
World Neurosurgery

Original Article
Treatment of Recurrent Intracranial Aneurysms After Clipping: A Report of 23 Cases and a Review of the Literature

https://doi.org/10.1016/j.wneu.2016.05.053Get rights and content

Objective

There are no established treatment strategies for aneurysms that recur after clipping. In this study, we present cases of patients who experienced recurrent aneurysms after clipping and subsequently underwent surgical intervention.

Methods

Between 2004 and 2015, we surgically treated 23 aneurysms that recurred at a previously clipped site. Patient characteristics and clinical history were retrospectively reviewed.

Results

Patients included 19 women and 4 men 45–81 years old. Aneurysms recurred 3–31 years (mean, 15.4 years) after the initial operation. For 18 cases, the first clinical presentation was a subarachnoid hemorrhage; aneurysms were incidentally diagnosed in 5 patients. Aneurysm locations were as follows: 9 on the internal carotid artery; 4 on the middle cerebral artery; 7 on the anterior communicating artery; 2 on the distal anterior cerebral artery; and 1 on the basilar artery. The reasons for retreatment included subarachnoid hemorrhage (n = 9) and aneurysm regrowth detected on follow-up examinations (n = 14). Endovascular treatment was performed in 10 cases, and direct surgery was performed in 13 cases (clipping in 8, clipping or trapping with bypass in 5). Various complex vascular reconstructions, including high-flow bypass and intracranial-intracranial in situ bypass, were performed for recurrent aneurysms.

Conclusions

In our experience, coil embolization is a safe and effective procedure for treating recurrent aneurysms. When cases are unsuitable for coil embolization, surgical treatment often requires neurosurgeons not only to overcome the general technical difficulty of reoperative clipping but also to perform challenging vascular reconstruction.

Introduction

Several studies have reported aneurysm regrowth at a previously clipped site,1, 2, 3, 4 and de novo aneurysm formation after clipping is an occasional but well-established occurrence.5, 6 Recurrent aneurysms have been treated with endovascular procedures7, 8, 9, 10, 11 and direct surgery,5, 9, 10, 12 but current reports have not discussed in detail the methods by which treatment procedures are chosen. Because the technical difficulties associated with reoperative procedures for recurrent aneurysms are well established,5 some authors have suggested endovascular coiling as a safe and effective retreatment option.7, 8, 9, 10, 11 Although progress in neuroendovascular procedures can make various complex aneurysms treatable,13, 14, 15 there are some cases of aneurysms deemed unsuitable for coil embolization, such as thrombotic aneurysms, giant aneurysms, and wide neck aneurysms. For these cases, we have had to perform a craniotomy procedure. These operations often require neurosurgeons to overcome the technical difficulties associated with severe adhesions when establishing an approach route and to create space around the aneurysm. In this article, we present 23 patients who had a recurrent aneurysm after clipping and underwent surgical interventions. These cases are thoroughly reviewed with a focus on direct surgical management.

Section snippets

Materials and Methods

The institutional review board approved this retrospective study; informed patient consent was not required. During the years 2004–2015, we performed 23 consecutive surgical procedures to treat saccular aneurysms that regrew at a previously clipped site. For patients with an aneurysm that required retreatment within 2 years after initial clipping, the initial treatments for these cases were regarded as having incomplete clipping, and the cases were excluded. Patient clinical records were

Patient Characteristics

Case summaries are presented in Table 1. Patients were 23–66 years old (mean ± SD, 49.0 years ± 13.1) at their first admission and 45–81 years old (mean ± SD, 64.5 years ± 10.8) at their second admission. Of the 23 patients, 19 were women. Recurrent aneurysms occurred 3–31 years (mean ± SD, 15.4 years ± 7.0) after the first operation. In 18 patients, the first clinical presentation was SAH; aneurysm was incidentally diagnosed in 5 asymptomatic patients. Aneurysm locations were as follows: 9 at

Discussion

Several authors have reported the use of coiling to treat aneurysms that recur after clipping7, 8 or have performed direct surgery to treat such aneurysms.5, 12 However, these reports have not clearly delineated the rationale behind the methods used to treatment recurrent aneurysms. Our institution has treated 23 cases of recurrent aneurysm. This report reviewed these cases with a focus on treatment strategies and outcomes. In our cohort, approximately half of the cases were relatively easy to

Conclusions

In our experience, coil embolization is a safe, effective, and very promising procedure for treating recurrent aneurysms, and it can be considered a first-line treatment option for suitable patients with recurrent aneurysms. In patients with aneurysms deemed unsuitable for coil embolization, surgical procedures often requires neurosurgeons not only to overcome the technical difficulties involved with reoperative clipping but also to perform technically demanding vascular reconstruction. For

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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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