Direct Surgery of Previously Coiled Large Internal Carotid Ophthalmic Aneurysm for the Purpose of Optic Nerve Decompression

Microsurgical management of previously embolized intracranial aneurysms: A single center experience and literature review

BACKGROUND

Endovascular treatment of intracranial aneurysms (IAs) provides less invasiveness and lower morbidity than microsurgical clipping, albeit with a long-term recurrence rate estimated at 20%. We present our single-center experience and a literature review concerning surgical clipping of recurrent previously coiled aneurysms.

METHODS

Retrospective analysis of nine (9) patients' data and final clinical/angiographic outcomes, who underwent surgical clipping of IAs in our center following initial endovascular treatment, over a 12-year period (2010-2022). Regarding the literature review, data were extracted from 48 studies including 969 patients with 976 aneurysms.

RESULTS

9 patients (5 males - 4 females) were included in the study with a mean age of 49 years. Subarachnoid hemorrhage was the initial presentation in 78% of patients. Aneurysms' most common location was the middle cerebral artery bifurcation (5/9) followed by the anterior communicating artery (3/9) and the internal carotid artery bifurcation (1/9). Indications for surgery were coil loosening, coil compaction, sac regrowth, and residual neck. Procedure-related morbidity and mortality were zero whereas complete aneurysm occlusion was achieved after surgical clipping in all cases (100%). All patients had minimal symptoms or were asymptomatic (mRS 0-1) at the final follow-up.

CONCLUSIONS

Surgical clipping seems a feasible and safe technique for selected cases of recurrent previously coiled intracranial aneurysms. A universally accepted recurrence classification system and a guideline template for the management of such cases are needed.

A comparative propensity-adjusted analysis of microsurgical versus endovascular treatment of unruptured ophthalmic artery aneurysms

OBJECTIVE

Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings.

METHODS

The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications.

RESULTS

A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications.

CONCLUSIONS

Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.

Outcomes of Retreatment for Intracranial Aneurysms — A Meta-Analysis

BACKGROUND

Long-term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment.

OBJECTIVE

To evaluate retreatment related outcomes.

METHODS

A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias.

RESULTS

Twenty-five articles that met the inclusion criteria were included in the meta-analysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95% confidence interval [CI]: 87.0-94.1) and a pooled mortality rate of 5.6% (95% CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95% CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95% CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95% CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95% CI: 11.4-92.7) and a pooled mortality rate of 9.3% (95% CI: 4.1-19.9). All pooled incidence rates were produced using random-effect models.

CONCLUSION

Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate.