Surgery of intracranial aneurysms previously treated endovascularly

Surgical Clipping of Previously Coiled Recurrent Intracranial Aneurysms: A Single-Center Experience

Objective: This study reviews our experiences in surgical clipping of previously coiled aneurysms, emphasizing on recurrence mechanism of intracranial aneurysms (IAs) and surgical techniques for different types of recurrent IAs.

Method: We performed a retrospective study on 12 patients who underwent surgical clipping of aneurysms following endovascular treatment between January 2010 and October 2020. The indications for surgery, surgical techniques, and clinical outcomes were analyzed.

Result: Twelve patients with previously coiled IAs were treated with clipping in this study, including nine females and three males. The reasons for the patients having clipping were as follows: early surgery (treatment failure in two patients, postoperative early rebleeding in one patient, and intraprocedural aneurysm rupture during embolization in one patient) and late surgery (aneurysm recurrence in five patients, SAH in one, mass effect in one, and aneurysm regrowth in one). All aneurysms were clipped directly, and coil removal was performed in four patients. One patient died (surgical mortality, 8.3%), 1 patient (8.3%) experienced permanent neurological morbidity, and the remaining 10 patients (83.4%) had good outcomes. Based on our clinical data and previous studies, we classified the recurrence mechanism of IAs into coil compaction, regrowth, coil migration, and coil loosening. Then, we elaborated the specific surgical planning and timing of surgery depending on the recurrence type of IAs.

Conclusion: Surgical clipping can be a safe and effective treatment strategy for the management of recurrent coiled IAs, with acceptable morbidity and mortality in properly selected cases. Our classification of recurrent coiled aneurysms into four types helps to assess the optimal surgical approach and the associated risks in managing them.

Microsurgery of residual or recurrent complex intracranial aneurysms after coil embolization - a quest for the ultimate therapy

The long-term stability of coil embolization (CE) of complex intracranial aneurysms (CIAs) is fraught with high rates of recanalization. Surgery of precoiled CIAs, however, deviates from a common straightforward procedure, demanding sophisticated strategies. To shed light on the scope and limitations of microsurgical re-treatment, we present our experiences with precoiled CIAs. We retrospectively analysed a consecutive series of 12 patients with precoiled CIAs treated microsurgically over a 5-year period, and provide a critical juxtaposition with the literature. Five aneurysms were located in the posterior circulation, 8 were large-giant sized, 5 were calcified/thrombosed. One presented as a dissecting-fusiform aneurysm, 9 ranked among wide neck aneurysms. Eight lesions were excluded by neck clipping (5 necessitating coil extraction); 1 requiring adjunct CE. The dissecting-fusiform aneurysm was resected with reconstruction of the parent artery using a radial artery graft. Three lesions were treated with flow alteration (parent artery occlusion under bypass protection). Mean interval coiling-surgery was 4.6 years (range 0.5-12 years). Overall, 10 aneurysms were successfully excluded; 2 lesions treated with flow alteration displayed partial thrombosis, progressing over time. Outcome was good in 8 and poor in 4 patients (2 experiencing delayed neurological morbidity), and mean follow-up was 24.3 months. No mortality was encountered. Microsurgery as a last resort for precoiled CIAs can provide-in a majority of cases-a definitive therapy with good outcome. Since repeat coiling increases the complexity of later surgical treatment, we recommend for this subgroup of aneurysms a critical evaluation of CE as an option for re-treatment.

Microsurgical ligation for incompletely coiled or recurrent intracranial aneurysms: a 17-year single-center experience

Background

In this retrospective single-center study, we presented our experience in the microsurgical management of incompletely coiled or recurrent aneurysms after initial endovascular coiling.

Methods

During a 17-year period, 48 patients underwent microsurgical clipping of incompletely coiled or recurrent aneurysms after coiling (Gurian group B). The clinical data, surgical technique, and postoperative outcome were recorded and analyzed.

Results

Before coiling, 42 patients (87.5%) experienced aneurysm rupture. Most of the aneurysms (46/48, 96%) were located in the anterior circulation. After coiling, 6 patients had incompletely coiled aneurysms and 42 patients had recurrent aneurysms, with a mean time of 20.2 months from coiling to recurrence. Coil extrusion occurred in none of the incompletely coiled aneurysms and 71% (30/42) of the recurrent aneurysms. Clipping techniques are direct microsurgical clipping without coil removal in 16 patients, partial coil removal in 14 patients, and total coil removal in 18 patients. Postoperative and follow-up angiography revealed complete occlusion of the aneurysms in all patients. No patient died during postoperative follow-up period (mean, 78.9 months; range, 10-190 months). Good outcomes (GOS of 4 or 5) were achieved in 87.5% (42/48) of the patients at the final follow-up.

Conclusions

Microsurgical clipping is effective for incompletely coiled or recurrent aneurysms after initial coiling. For recurrent aneurysms that have coils in the neck, have no adequate neck for clipping, or cause mass effects on surrounding structures, partial or total removal of coiled mass can facilitate surgical clipping and lead to successful obliteration of the aneurysms.

Microvascular Revascularization for Recurrent A1 Anterior Cerebral Artery Aneurysm Postendovascular Treatment: A Case Report and Review of the Literature

The recurrence of aneurysms postcoil embolization is a common occurrence. Endovascular coiling has been noted to be more effective for small lesions rather than the giant aneurysms. A postembolization recurrent aneurysm is a difficult condition to manage. We present a case of a recurrent giant aneurysm of the anterior cerebral arteries (ACAs) first segment (A1). It was managed by superficial temporal artery to A3 segment of anterior cerebral artery bypass anastomotic revascularization plus distal A1- segment clipping. A literature review is presented for the management of giant A1 artery aneurysms.

Surgical Clipping of Previously Ruptured, Coiled Aneurysms: Outcome Assessment in 53 Patients

BACKGROUND

Occasionally, previously coiled aneurysms will require secondary treatment with surgical clipping, representing a more complicated aneurysm to treat than the naïve aneurysm. Patients who initially presented with a ruptured aneurysm may pose an even riskier group to treat than those with unruptured previously coiled aneurysms, given their potentially higher risk for rerupture. The objective of this study was to assess the clinical outcomes of patients who undergo microsurgical clipping of ruptured previously coiled cerebral aneurysms. In addition, we present a thorough review of the literature.

METHODS

A total of 53 patients from a single institution who initially presented with a subarachnoid hemorrhage and underwent surgical clipping of a previously coiled aneurysm between December 1997 and December 2014 were studied. Clinical features, hospital course, and preoperative and most recent functional status (Glasgow Outcome Scale score) were reviewed retrospectively.

RESULTS

The mean time interval from coiling to clipping was 2.6 years, and mean follow-up was 5.5 years (range, 0.1-14.7 years). Five patients (9.8%) presented with rebleed prior to clipping. Most patients (79.3%, 42/53) experienced good neurologic outcomes. Most showed no change (81%, 43/53) or improvement (13%, 7/53) in functional status after microsurgical clipping. One patient (2%) deteriorated clinically, and there were 2 mortalities (4%).

CONCLUSIONS

Microsurgical clipping of previously ruptured, coiled aneurysms is a promising treatment method with favorable clinical outcomes.

Surgical management of recurrent aneurysms after coiling treatment

OBJECTIVE

Aneurysms that recur after coiling treatment are difficult to manage. The microsurgical technique in these cases differs significantly from that in regular aneurysm clipping. We present our experience in surgical management of aneurysms that recurred more than 1 month after coiling in a series of 19 patients.

MATERIALS AND METHODS

Between January 2004 and December 2014, 1437 patients were treated surgically for intracranial aneurysms in our institution. We performed a retrospective review of the clinical records, operation videos, and cerebral angiograms. We focused on patients in whom the initial aneurysm was treated by coiling, but the results were incomplete or the aneurysm recurred.

RESULTS

Nineteen patients underwent surgical clipping for recurrent aneurysm more than 1 month after initial coiling treatment. The sex ratio (male:female) was 0.9, and the average age was 51.3 years (range 35-72 years). One aneurysm was classified as giant (≥ 25 mm), two as large (10-25 mm), and 18 as small (≤ 10 mm). A good outcome (Glasgow Outcome Scale 4 or 5) was observed in 16 of 19 patients (84.2%).

CONCLUSION

Microsurgical clipping can be safe and effective in the management of previously coiled residual and recurrent aneurysms.

Intracranial post-embolization residual or recurrent aneurysms: Current management using surgical clipping

Post-embolization residual or recurrent aneurysms (PERRAs) are not rare in patients with intracranial aneurysms treated by embolization. Their occurrence is mainly associated with an increased amount of interventional therapy. Repeated interventional embolization can be applied in some patients with PERRAs, whereas surgical clipping is preferred in other cases that are not suitable for repeated interventional embolization due to the difficulties inherent to this operation. The surgical clipping of PERRAs is very complicated and difficult to perform, and relevant reports are rare. This study offers a review of PERRA treatment using surgical clipping. Retrospective studies have shown that PERRAs are common aneurysms of the anterior and posterior communicating arteries. According to the recurrent characteristics of PERRAs, it is reasonable to categorize PERRAs into three types: type I-coils are compressed, and no embolic material fills the neck of the aneurysm; type II-coils are migrated, and very few coils fill the neck of the aneurysm or the parent artery; and type III-coils are migrated, and multiple coils fill the neck of the aneurysm or the parent artery. Direct clipping can be applied to types I and II PERRAs, whereas trapping, wrapping, or auxiliary revascularization is required in type III PERRAs. Most coils do not require removal unless they interfere with clipping. However, it is necessary to avoid damaging the surrounding adhesive tissue during coil removal. Satisfactory therapeutic outcomes can be achieved by selecting appropriate PERRA cases in which to perform surgical clipping.

Safety and efficacy of microsurgical treatment of previously coiled aneurysms: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review of the literature to evaluate the safety and efficacy of surgical treatment of previously coiled aneurysms.

METHODS

A comprehensive review of the literature for studies on surgical treatment of previously coiled aneurysms was conducted. For each study, the following data were extracted: patient demographics, initial clinical status, location and size of aneurysms, time interval between initial/last endovascular procedure and surgery, surgical indications, and microsurgical technique. We performed subgroup analyses to compare direct clipping versus coil removal and clipping versus parent vessel occlusion, early (<4 weeks post-coiling) versus late surgery and anterior versus posterior circulation.

RESULTS

Twenty-six studies with 466 patients and 471 intracranial aneurysms were included. All of the studies were retrospective and non-comparative case-series. Patients undergoing direct clipping had lower perioperative morbidity (5.0 %, 95 % CI = 2.6-7.4 %) when compared to those undergoing coil removal and clipping (11.1 %, 95 % CI = 5.3-17.0 %) or parent vessel occlusion (13.1 %, 95 % CI = 4.6-21.6 %) (p = 0.05). Patients receiving early surgery (<4 weeks post-coiling) had significantly lower rates of good neurological outcome (77.1 %, 95 % CI = 69.3-84.8 %) when compared to those undergoing late surgery (92.1 %, 95 % CI = 89.0-95.2 %) (p < 0.01). There were higher rates of long-term neurological morbidity in the posterior circulation group (23.1 vs. 4.7 %, p < 0.01) as well as long-term neurological mortality (4.4 vs. 2.8 %, p < 0.01).

CONCLUSIONS

Our meta-analysis suggests that surgical treatment is safe and effective. Our data indicate that aneurysms that are amenable to direct clipping have superior outcomes. Late surgery was also associated with better clinical outcomes. Surgery of recurrent posterior circulation aneurysms was associated with high rates of morbidity and mortality. Given the characteristics of the included studies, the quality of evidence of this meta-analysis is limited.

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

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.

Balloon-assisted coiling of the proximal lobule of a paraophthalmic aneurysm causing panhypopituitarism: Technical case report

Background:

We describe an intra-aneurysmal balloon-assisted technique to limit the coil volume in a large bilobulated paraophthalmic aneurysm. Our intent was to reduce the mass effect and presenting symptoms of diabetes insipidus (DI) with hypopituitarism.

Case Description:

A 32-year-old woman presented with symptoms of DI and her work-up demonstrated hypopituitarism and partial bitemporal visual field defects. Cerebral angiography revealed a large paraophthalmic aneurysm with two distinctive lobules, projecting toward the pituitary fossa. The patient declined craniotomy but consented for endovascular treatment. The plan was to limit the embolization to the proximal lobule only. Initially, we used a dual microcatheter technique with a microcatheter in each lobule. A framing coil in the distal lobule did not prevent coil migration from the proximal lobule. Instead, we elected to use a Hyperform balloon in the distal lobule and were able to successfully coil the proximal lobule only. Her 3-year follow-up angiogram revealed a completely occluded aneurysm. The patient experienced resolution of the DI and improvement of her visual fields. However, she remained in hypopituitarism.

Conclusion:

Intra-aneurysmal balloon-assisted coiling of proximal aneurysmal lobules might be an alternative for the reduction of mass effect related to the coil mass. Careful follow-up is needed because subtotal occlusion carries a future risk of growth, recanalization and rupture. Unruptured intracranial carotid aneurysms can present with reversible DI and usually permanent pituitary disturbances.

Early and late microsurgical clipping for initially coiled intracranial aneurysms

INTRODUCTION

An increasing number of patients with incompletely treated and recurrent intracranial aneurysms are presenting for further management. We review the patients who underwent microsurgical clipping of previously coiled intracranial aneurysms.

METHODS

From 2001 to 2008, we treated 623 aneurysms by endovascular treatment. Among them, 29 patients underwent microsurgical clipping. Nineteen patients (group A) underwent early surgical intervention due to incomplete coiling, a residual neck, coil protrusion, aneurysm rupture, or coil stretching. Ten patients (group B) underwent surgical clipping for recurrent aneurysm and an increased mass effect during the follow-up period. The radiographic images and clinical data were reviewed retrospectively to determine the treatment efficacy, the clinical outcomes, and the factors that are important to select the proper treatment modality.

RESULTS

There were 13 female and 16 male patients. The coils were removed in 6 of the 19 patients in group A and in 1 of the 10 patients in group B. Seventeen (89.5%) of the 19 patients in group A and all the patients (100%) in group B achieved good recovery (Glasgow Outcome Scale 5 and 4) during the clinical follow-up periods (mean 25.2 months).

CONCLUSION

Microsurgical clipping may be chosen as a safe and permanent treatment option for the previously coiled aneurysms with acceptable morbidity in properly selected cases.

Detachable coil embolisation of ruptured intracranial aneurysms: a single center study, a decade experience

OBJECTIVE

The introduction of detachable coils revolutionised the management of patients with intracranial aneurysms and is now considered a first-line treatment in our institution. The purpose of this study was to review 10 years of experience with this method.

METHODS

A retrospective review of prospectively collected data on 711 patients undergoing endovascular treatment of ruptured intracranial aneurysm between 1996 and 2005 with regard to technical feasibility, procedural complications, rebleeding, anatomical outcome, need for retreatment and overall clinical outcome.

RESULTS

Endovascular treatment failed in 25 aneurysms from a total of 717 (4%). Aneurysm rupture complicated 37 procedures (4.7%) leaving 10 patients permanently disabled or dead (1.3%). Thromboembolic events complicated 35 procedures (4.5%) leaving 8 patients permanently disabled or dead (1%). One other patient died because of fatal parent vessel rupture. Further 6 procedures were complicated by arterial dissection and 18 by coil loop protrusion, however all of these patients achieved independent recovery. Overall morbidity-mortality was 2.9%. Further subarachnoid hemorrhage occurred in 16 patients (2.3%), 12 of which died. Altogether, 121 aneurysms from 511 (24%) were recanalized on follow up angiography, 52 required retreatment (7.1%). At 6 months follow up, 580 patients (82%) were independent, while 130 patients (18%) were disabled or dead.

CONCLUSION

Detachable coil embolisation of intracranial aneurysms is a very feasible treatment method associated with a small risk of permanent morbidity-mortality. Risk of further bleeding is small, but related with devastating outcome. Approximately 25% of aneurysms will recanalize and 7% will require retreatment. Despite these shortcomings, vast majority of patients will achieve independent recovery.

Technical challenges to surgical clipping of aneurysmal regrowth with coil herniation following endovascular treatment - a case report

In recent years, technical developments have made endovascular procedures attractive therapeutic options and enabled the endovascular surgeon to redefine the management of cerebral aneurysms. However, as the number of aneurysms undergoing endovascular therapy has grown, so has the number of patients with incompletely treated aneurysms who are presenting for further management. In cases of failure of endovascular treatment caused by either incomplete occlusion or regrowth of the aneurysm, a complementary treatment is often necessary. Surgical treatment of these patients is challenging. We present a case of a ruptured posterior cerebral artery aneurysm treated initially with endovascular coiling that left behind significant residual aneurysmal sac. Regrowth of the aneurysm documented on follow-up was treated surgically. At surgery, the coil was found to have herniated through the aneurysmal sac into the subarachnoid space, and the aneurysm was successfully clipped without removing the coils. We review the regrowth of aneurysms following endovascular therapy and potential problems and challenges of surgically managing these lesions.