Complementary management of partially occluded aneurysms by using surgical or endovascular therapy

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.

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.

Frequency and risk factors for postoperative aneurysm residual after microsurgical clipping

OBJECTIVE

Aneurysm residuals after clipping are a well-known problem, but the course of aneurysm remnants in follow-up is not well studied. No standards or follow-up guidelines exist for treatment of aneurysm remnants. The aim of this study was to evaluate the risk factors for postoperative aneurysm remnants and their changes during follow-up.

METHODS

We performed a retrospective analysis of 666 aneurysms treated via clipping in our hospital from 2006 to 2016. Postoperative and follow-up angiographic data were analyzed for aneurysm remnants and regrowth. Clinical parameters and aneurysm-specific characteristics were correlated with radiological results.

RESULTS

The frequency of aneurysm residuals was 12% (78/666). Aneurysms located in the middle cerebral artery (p = 0.02) showed a significantly lower risk for incomplete aneurysm occlusion. Larger aneurysms with a diameter of 11-25 mm (p = 0.005) showed a significantly higher risk for incomplete aneurysm occlusion. Five patients underwent re-clipping during the same hospital stay. Remnants were stratified based on morphological characteristics into "dog ears" (n = 60) and "broad based" (n = 13). The majority of the "dog ears" stayed stable, decreased in size, or vanished during follow-up. Broad-based remnants showed a higher risk of regrowth.

CONCLUSIONS

A middle cerebral artery location seems to lower the risk for the incomplete clip occlusion of an aneurysm. Greater aneurysm size (11-25 mm) is associated with a postoperative aneurysm remnant. The majority of "dog-ear" remnants appear to remain stable during follow-up. In these cases, unnecessarily frequent angiographic checks could be avoided. By contrast, broad-based residuals show a higher risk of regrowth that requires close imaging controls if retreatment cannot be performed immediately.

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.

[The principles for choosing a surgical technique for patients with acute cerebral aneurysm rupture]

The article describes the principles for choosing a surgical technique for patients with cerebral aneurysms in acute subarachnoid hemorrhage. The principles were developed based on the experience gained at the Burdenko Neurosurgical Institute. Microsurgical and endovascular treatment options are considered.

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.

The combined treatment of stenting and surgery in a giant unruptured aneurysm of the middle cerebral artery

BACKGROUND

This case study reports on a combined therapy of stenting and surgery for a giant unruptured middle cerebral artery (MCA) aneurysm with the aim of preserving the patency of the vessel during surgery.

CASE DESCRIPTION

A 51-year-old male presented with a sudden onset of moderate left hemiparesis and dysarthria. Neuro-radiological evaluations showed a giant right unruptured MCA aneurysm without subarachnoid hemorrhage (SAH). The cerebral angiography confirmed the presence of such an aneurysm producing compression of both M2 branches with consequent slowing of the blood flow. Two weeks later, the patient underwent the positioning of an Enterprise stent and inside this, a flow diverter Silk stent. They were placed across the aneurysm and in one of the two M2 branches with the aim of protecting them during surgical manipulation. The patient went immediately to surgery, where the aneurysm was resected and both M2 branches decompressed.

CONCLUSION

The combined placement of the stents allowed safe and successful surgical dissection of the M2 branches and clipping of the aneurysm without interrupting the blood flow.

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.

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.

Neurosurgical treatment for aneurysm remnants or recurrences after coil occlusion

OBJECTIVE

Neurosurgical management of residual aneurysms (RA) after coiling remains a challenging issue. We present a consecutive series of 21 patients who underwent microsurgical treatment of a previously coiled aneurysm.

METHODS

We retrospectively reviewed a consecutive series of 21 patients who underwent operations for an RA after coiling between 1997 and 2007. Postcoiling follow-up imaging included brain magnetic resonance angiography and digital subtraction angiography. The decision for surgical treatment was made when an RA was significant and unsuitable for re-embolization. Data related to the RA and to the surgical technique were analyzed. Postoperative outcome was evaluated with the Glasgow Outcome Scale.

RESULTS

Twenty aneurysms were initially ruptured. Twelve had undergone complete coil occlusion, whereas 6 had a residual neck, 2 had a residual lobule, and 1 had a residual sac. The aneurysms were in the anterior circulation in 18 cases and in the posterior circulation in 3 cases. Twenty RAs were excluded with the apposition of 1 clip beneath the coils, 2 required a temporary occlusion, 2 required extraction of the coils, and 1 presented with an operative rupture. All aneurysms, except 2 that had their residual neck wrapped, were completely occluded. The postoperative Glasgow Outcome Scale score was unchanged in 90% of patients, and 2 patients sustained a moderate disability.

CONCLUSION

Microsurgical treatment of RA after endovascular treatment is effective, provided that patients are selected appropriately. The surgical treatment of recanalized aneurysms after coiling is challenging but can result in a good outcome with low morbidity and no mortality.

SURGICAL MANAGEMENT OF A PARACLINOID ANEURYSM CONTAINING A DISPLACED NEUROFORM MICROSTENT

OBJECTIVE

We report the first case of clip obliteration of a cerebral aneurysm containing a displaced microstent.

CLINICAL PRESENTATION

A 63-year-old woman presented with a 6-month history of headaches. She had no other neurological symptoms, and her examination was normal. A computed tomographic scan showed no evidence of hemorrhage. Angiography confirmed the presence of a large left paraclinoid aneurysm.

INTERVENTION

The patient initially underwent attempted endovascular repair of the aneurysm. A Neuroform microstent (Boston Scientific, Natick, MA), which was placed across the aneurysm neck, migrated into the aneurysm upon passing through it with the microcatheter to be used to place coils. This left the proximal half of the stent in the aneurysm and the distal half in the internal carotid artery. Attempts to remove the stent and to place a second stent across the neck of the aneurysm failed, and any plans to place coils were aborted. Three months after the failed endovascular procedure, the patient consented to a craniotomy. The aneurysm was successfully obliterated by placing several clips directly across the neck of the aneurysm and leaving the stent in place.

CONCLUSION

The patient experienced an excellent clinical and angiographic outcome. Although not the ideal treatment strategy, this report illustrates that clip obliteration of aneurysms containing displaced microstents can be performed successfully for this complication of endovascular treatment.

Retreatment of cerebral aneurysms after guglielmi detachable coil embolization

SUMMARY

Of 175 patients with 181 aneurysms initially treated with Guglielmi Detachable Coils (GDC), 25 were retreated. All retreatments except one were performed on previously ruptured aneurysms. Thirteen aneurysms were retreated because of recurrence, and 12 aneurysms were retreated to complete initial insufficient embolization. Sixteen patients underwent re-embolization and 9 patients were operated upon surgically. No complications related to the retreatment were experienced. We consider that repeat embolization should be attempted before considering surgical treatment in case that additional therapy is required. However, it is difficult to retreat aneurysms having wide necks. In regard to surgical clipping, aneurysms without a coil in the neck are easier to treat with primary clipping, whereas aneurysms with a coil mass in the neck are difficult to surgical clip. We have never used temporary clipping and coil extraction if the distance between the coil and the parent artery was wider than 2 mm. Emerging new embolic agents or devices and technical improvement might decrease the need for retreatment and increase long-term efficacy after endovascular treatment.

Management of complex, surgically intractable intracranial aneurysms: the option for intentional reconstruction of aneurysm neck followed by endovascular coiling

BACKGROUND

A limited series of patients with aneurysm were reviewed retrospectively to analyze strategies for integrating microsurgical and endovascular techniques in the management of complex, surgically intractable aneurysms.

METHODS

Four patients were managed in Fujita Health University with a multimodality approach: intentional reconstruction of the aneurysm neck followed by endovascular coiling.

RESULTS

A total of 5 aneurysms were treated, of which 3 were large or giant in size, and 3 were fusiform or multilobulated. Complete angiographic obliteration was confirmed in 4 aneurysms (80%). All patients had a good outcome (Glasgow Outcome Scale score 5; mean follow-up, 64 months).

CONCLUSION

As for complex, surgically intractable aneurysms, the intentional reconstruction of the aneurysm neck followed by endovascular coiling should be considered more often.

Recurrent hemorrhage after initially complete occlusion of intracranial aneurysms

Recurrent hemorrhage in the case of incompletely treated aneurysms is well known. The authors present a series of patients in whom rebleeding occurred in spite of totally occluded aneurysms. During a period of 12 years, 1170 patients with intracranial aneurysms were treated using either clipping (n=727) or coiling (n=443). In 11 of them, intracranial rebleeding occurred, in seven of whom routine post-treatment angiography revealed total aneurysm occlusion before the appearance of rehemorrhage. Further analysis focused on these seven patients. Their recurrent aneurysm ruptures happened with a mean latency of 9.5 months (range 21 h-48 months) from initial treatment. All aneurysms belonged to the anterior circulation. Three patients underwent primary clipping, and four experienced coiling first. The intracranial hemorrhages appeared mainly as intracerebral hematomas. The angiographically documented recurrent aneurysm configurations were caused by clip slippage (n=2), coil compaction (n=3), or coil migration/dislocation (n=1). In one case with primary surgery, clip slippage was possible but not confirmed by intraoperative view, because the patient died before therapeutic intervention. Two patients did not undergo therapy because of their poor clinical condition and died. Four of the remaining patients underwent clipping of the recurrent lesions, and one had recoiling. Final outcome was excellent/good in only two patients. The mainly poor outcome after rebleeding was caused by the high incidence of intracerebral hemorrhage.