Microsurgical Clipping for Recurrent Aneurysms After Initial Endovascular Coil Embolization

Ceramic Aneurysm Clip with Titanium Spring

OBJECTIVE

To design and evaluate ceramic aneurysm clips with integrated titanium springs, focusing on ergonomic application and precision in neurosurgical procedures.

METHODS

The clip design was executed with precision using Creo Parametric 3D CAD software. It comprises a zirconia body and a titanium spring for durability and consistent tension and features a four-coil hairpin titanium spring for enhanced closing force and a ball-type head for versatile maneuverability during surgery. To assess durability, closing forces were rigorously measured using a force gauge system, comparing the ceramic clip with the standard Mizuho permanent clip over 30 open-close cycles. For the assessment of magnetic resonance (MR) artifacts, both the ceramic and Yasargil clips were evaluated using a 3 Tesla (T) MRI scanner, employing specific imaging sequences.

RESULTS

The straight type ceramic clip's initial closing force was 1.70 N, dropping to 1.22 N after 30 cycles, indicating a retention of 72% of its initial force. In MRI, the ceramic clip displayed significantly lower measurement discrepancies compared to the titanium alloy Yasargil clip, particularly in high-resolution T1-weighted images. The lowest variance was at measurement point L2, where the ceramic clip showed a 3% discrepancy. Furthermore, the ceramic clip yielded clearer images than the titanium alloy clip, particularly at the clip's end.

CONCLUSIONS

Ceramic clips with titanium springs demonstrated satisfactory closing force and superior MRI compatibility, promising enhancements in surgical application and postoperative assessment.

Microsurgical Treatment of Previously Coiled Giant Aneurysms: Experience with 6 Cases and Literature Review

OBJECTIVE

Surgical treatment of insufficiently embolized (coiled) or recurrent giant aneurysms has not been well established in the literature. The aim of this study is to bring up the surgical difficulties of these rare aneurysms and to offer solutions.

METHODS

A database was queried for giant aneurysms that had been previously embolized and subsequently required surgical treatment. We only found 29 aneurysms in the literature and here, we report 6 more surgical cases with patient characteristics, radiological studies, applied surgical techniques, and outcomes which were reviewed retrospectively.

RESULTS

Four females and 2 males, with a mean age of 45.6 years took part in the study. The most common aneurysm location was the middle cerebral artery. While 5 aneurysms were successfully clipped, 1 was excised and the neck was closed with micro sutures. The coils were compulsorily removed in 3 patients. Postoperative digital subtraction angiography confirmed total occlusion of the aneurysms in all cases. Overall morbidity was 16.6%. There was no mortality. No recurrence was observed in the angiographic follow-up (mean 22.6 months, range 7-47 months). The literature review also determined that 97.1% of 35 previously coiled giant aneurysms (including ours) were occluded using various surgical techniques, with 82.8% good outcome.

CONCLUSIONS

Surgical clipping is a safe and effective procedure for the treatment of insufficiently embolized or recurrent giant aneurysms after coiling. If possible, the coils should not be removed. However, if safe clipping is not possible due to the coils, the removal of the coils should not be avoided.

Adhesion between an extruded coil and the oculomotor nerve: Unexpected interference due to coil extrusion

Background:

When direct clipping is performed for a recurrent aneurysm after coil embolization, there are sometimes findings of the coil adhering to the surrounding tissue, after it has been extruded from inside the aneurysm into the subarachnoid space and brain parenchyma. However, there have only been few previous reports on extruded coils adhering to the cranial nerves, preventing aneurysm dissection and clip application.

Case Description:

We performed the coil embolization of a ruptured aneurysm originating from the bifurcation of basilar artery and superior cerebellar artery in a 36-year-old male patient. Recurrence was confirmed 5 years after embolization and direct clipping was performed. The intraoperative finding was that part of the coil was strongly adhering to or encircling the oculomotor nerve, making it difficult to achieve sufficient mobility of the cerebral aneurysm.

Conclusion:

When direct clipping is performed after coil embolization of an intracranial aneurysm, part of the coil may be extruded from the aneurysm and then adhere strongly to the cranial nerve.

Microsurgical Clipping of Intracranial Aneurysms in the Endovascular Era

The treatment of intracranial aneurysms (IA) began in the late 19th century. Some degree of controversy has always surrounded the best treatment modality for IA. Cushing and Dandy debated about cervical carotid ligation as the only surgical alternative before the introduction of microsurgical clipping. In the early 21st century, the debate has centered on surgical versus^ endovascular techniques. With the advent of newer endovascular techniques and devices, there has been a dramatic shift in treatment paradigms toward endovascular intervention that is preferred by both physicians and patients. However, there will always be a need for microsurgical cerebrovascular expertise since some aneurysms cannot or should not be embolized. This creates a difficult conundrum as only the most complex of aneurysms will require open surgery, but the lack of volume and training will be a challenge in teaching and maintaining the surgical expertise required to safely treat them. The purpose of this review is to discuss the history of IA treatment and critically evaluate the current state of the art of IA treatment, with a specific focus on the necessary role microsurgical clipping continues to play in the current treatment landscape.

Partial Clipping Occlusion Including Rupture Point Is an Effective Strategy for Ruptured Giant Fusiform Basilar Artery Aneurysm: A Technical Case Report

Treatment of fusiform basilar artery aneurysms is still challenging today. The authors present a case of a patient with a ruptured giant fusiform basilar artery aneurysm successfully treated by clipping occlusion of the rupture point. A 62-year-old man suddenly fell into a coma due to subarachnoid hemorrhage (SAH) with a ruptured giant fusiform basilar artery aneurysm with a bleb on the right shoulder. We considered treating the lesion with stent-assisted coil embolization because of the aneurysm's shape, but we had to give up because stents were off-label in the acute phase SAH in our country. Instead, we successfully performed clipping surgery to partially occlude the aneurysm, including the rupture point via the anterior transpetrosal approach. His postoperative course was uneventful, without rerupture of the aneurysm, and his conscious level tended to improve. The postoperative imaging studies showed no complications and disappearance of the rupture point of the aneurysm. Although direct surgery for the giant fusiform basilar artery aneurysms is one of the challenging operations, it is an essential and highly effective treatment as a last resort for complex aneurysms if other treatments are not available.

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.

Institutional Experience of Microsurgical Management in Posterior Circulation Aneurysm

Introduction:

Posterior circulation aneurysm constitutes 15%–20% of all intracerebral aneurysms. With the advancement of endovascular techniques, the microsurgery for posterior circulation aneurysms has been pushed back a little. Even the International Subarachnoid Aneurysmal Trial gave support to the concepts of endovascular procedures, but microsurgical modality should not be discouraged. We present our institutional experience of microsurgical techniques on posterior circulation aneurysms.

Materials and Methods:

We performed a retrospective analysis of 37 patients of posterior circulation aneurysm from 2015 to 2019, referred to Bantane Hospital, Japan. We included all posterior circulation aneurysms such as basilar tip, basilar trunk, and vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms, admitted and treated with clipping or bypass and trapping. We assessed the outcome as measured by modified Rankin Score (mRS), complications, and mortality.

Results:

Out of 37 patients, 10 cases were a basilar tip, one case was the basilar trunk, and 26 cases were VA-PICA aneurysm. Intraoperatively, neuromonitoring, indocyanine green dye, dual-image videoangiography (DIVA), and neuro endoscope were used. Two patients of basilar tip aneurysm developed third cranial nerve paresis and six patients of VA-PICA aneurysm developed lower cranial nerve paresis which resolved spontaneously. All the patients were discharged with mRS of 0 or 1. No mortality was recorded in our study.

Conclusion:

Microsurgical clipping of posterior circulation aneurysm is safe in unruptured aneurysm with a very low risk of mortality and morbidity under experienced hands. All postoperative complications in our study were transient and resolved with time with no residual deficits. Preoperative simulation, intraoperative neuromonitoring, DIVA, and neuro endoscope help achieve complete obliteration of aneurysmal sac and avoid complications.

Definitive Treatment With Microsurgical Clipping After Recurrence and Rerupture of Coiled Anterior Cerebral Artery Aneurysms

BACKGROUND

The extent of obliteration of ruptured intracranial aneurysms treated with coil embolization has been correlated with the risk of rerupture. However, many practitioners consider that a small neck remnant is unlikely to result in significant risk after coiling.

OBJECTIVE

To report our recent experience with ruptured anterior cerebral artery aneurysms treated with endovascular coiling, which recurred or reruptured, requiring microsurgical clipping for subsequent treatment.

METHODS

Retrospective review of patients with intracranial aneurysms treated at our institution since August 2018. Patient and aneurysm characteristics, initial and subsequent treatment approaches, and outcomes were reviewed.

RESULTS

Six patients were included. Out of those 6 patients, 5 patients had anterior communicating artery aneurysms, and 1 patient had a pericallosal aneurysm. All initially presented with subarachnoid hemorrhage (SAH) and were treated with coiling. Recurrence occurred at a median of 7.5 mo. In 2 cases, retreatment was initially performed with repeat endovascular coiling, but further recurrence was observed. Rerupture from the residual or recurrent aneurysm occurred in 3 cases. In 2 cases, the aneurysm dome recurred; in 1 case, rerupture occurred from the neck. All 6 patients underwent treatment with microsurgical clipping. Follow-up catheter angiography demonstrated a complete occlusion of the aneurysm in all cases with the preservation of the parent vessel.

CONCLUSION

Anterior cerebral artery aneurysms may recur after endovascular treatment, and even small neck remnants present a risk of rerupture after an initial SAH. Complete treatment requires a complete exclusion of the aneurysm from the circulation. Even in cases that have been previously coiled, microsurgical clipping can represent a safe and effective treatment option.

Microsurgical treatment for the recurrent cerebral aneurysm initially treated using coil embolization

OBJECTIVE

Microsurgical treatment could be a good alternative for the treatment of recurrent cerebral aneurysm after coil embolization. The purpose of this study was to present our experience of microsurgical treatment for recurrent cerebral aneurysm previously treated using coil embolization.

METHODS

From June 2012 to May 2019, 34 patients consecutively received microsurgical treatment for a recurrent cerebral aneurysm previously treated using coil embolization after it ruptured.

RESULTS

Of the 34 patients with aneurysm, 33 had the aneurysm located in the anterior circulation. The most common location was the anterior communicating artery (13 cases). Immediate radiologic outcome at coil embolization was completed (n=6), residual neck (n=26), and residual sac (n=2). The reason for microsurgical treatment included rebleeding (n=12), persistent residual sac (n=1), and recurrence on follow-up study (n=21). Rebleeding occurred within 10 days after coil embolization in 10 cases, and the other 2 were due to regrowth. In the 20 recurred and saccular aneurysms, coil compaction was present in 11 aneurysms and regrowth in 9 aneurysms. Simple neck clipping (n=29) and clipping with coil mass extraction (n=3) was possible in the saccular aneurysms. The blood blister like aneurysm (n=2) were treated using bypass and endovascular internal carotid artery trapping. In the follow-up study group after microsurgical treatment there were no severe complications due to the treatment. Age, cause of retreatment, and modified Rankin Scale before microsurgery were associated with good outcome (p<0.001).

CONCLUSIONS

Microsurgical treatment may be a viable and effective option for treating recurrent aneurysms previously treated by endovascular techniques.

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.

Management of Recurrent Aneurysms after Endovascular Coiling: A Fujita Experience

Introduction:

Microsurgical clipping and Endovascular coiling (EC) are both effective alternatives in the management of intracranial aneurysms. EC has been shown to be associated with the risk of recurrent aneurysm (RA) growth. Considering the minimally invasive nature of this procedure, the management of intracranial aneurysms has been skewed toward EC, especially in the developed world. In this scenario, there has been an upsurge of RAs after EC. Since the optimal management of these RAs has not been defined, they pose a unique challenge to the treating surgeons.

Aims and Objectives:

The aim of this study is to elucidate the optimal management of RAs after EC.

Materials and Methods:

Medical records of all patients who underwent surgery for RAs were reviewed from the period January 2014 to March 2019. The demographic and angiographic patterns of the patients and operative techniques and complications were studied. The outcome was dichotomized into good and bad depending on the Glasgow outcome scale (GOS).

Results:

There were four cases of RAs operated in our institution between the above-mentioned period. There were varied differences between the initial coiling and time to recurrences. All four patients were operated under neuromonitoring. Three underwent clipping and one patient underwent clipping with bypass. All four patients had good outcome with a GOS of 5/5.

Conclusion:

Operations for RAs constitute many technical challenges and require a lot of expertise. Such surgeries are recommended in high-volume centers, with sufficient experience in both clipping and cerebral bypass.

Feasibility of Smart Metal Artifact Reduction Algorithm on Computed Tomography Angiography for Clipping of Recurrent Aneurysms After Coil Embolization

BACKGROUND

The number of patients with a history of clipping of recurrent aneurysms after coil embolization has increased. The aim of this article was to report the feasibility of CT angiography using a commercial metal artifact reduction algorithm (Smart Metal Artifact Reduction [MAR]) for patients who underwent clipping of recurrent aneurysms after coil embolization.

METHODS

Six cases of clipping of recurrent aneurysms after coil embolization were examined with CT angiography using MAR between 2015 and 2018 at a single institution. Conventional CT angiography and three-dimensional digital subtraction angiography data were compared, and depiction of the status of treated aneurysms using MAR was estimated.

RESULTS

Conventional CT angiography was unable to depict the status of treated aneurysms in the patients with a history of clipping of recurrent aneurysms after coil embolization because of metal artifacts. With MAR, metal artifacts were greatly reduced, and the status of treated aneurysms was able to be depicted, although depiction was inferior to three-dimensional digital subtraction angiography.

CONCLUSIONS

For patients with a history of clipping of recurrent aneurysms after coil embolization, CT angiography using MAR is feasible, although further development of imaging techniques is needed.

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.

Clipping of Recurrent Cerebral Aneurysms After Coil Embolization

BACKGROUND AND AIMS

To assess the technical points of surgical clipping for recurrent aneurysms after coiling, we examine a consecutive series of 14 patients who underwent re-treatment.

MATERIALS AND METHODS

From 2009 to 2016, 27 recurrent aneurysms after coiling were re-treated with endovascular treatment or surgical clipping. Of these, 14 were re-treated surgically. In cases where the remnant neck was sufficiently large, neck clipping was chosen. Where the remnant neck was too small and the border between the thrombosed and non-thrombosed portion was distinct, partial clipping was chosen. Surgical clipping was attempted without removing the coils when technically feasible.

RESULTS

Among the 14 cases, neck clipping was performed in 11, partial clipping in 2, and trapping with bypass in 1 case. Clipping without removal of coils was accomplished in all cases. No neurological deterioration occurred after surgical clipping in any case.

CONCLUSION

Clipping of recurrent aneurysms after coiling can compensate for the failure of initial endovascular therapy. For clipping without removal of coils, precise evaluation of the remnant neck is required. Bypass surgery is key to treatment in the case of aneurysm trapping.

Engaging in a Keyhole Concept for the Management of Ruptured and Unruptured Aneurysms

OBJECTIVE

Many new endovascular devices have been used under the guidance of the International Subarachnoid Aneurysm Trial. Clipping still offers higher occlusion rates, and its technique continues to evolve, resulting in smaller exposures and reduced manipulation to brain tissue. We sought to evaluate the routine use of the minisphenoidal approach to manage intracranial aneurysms in a high-volume institution.

METHODS

We retrospectively reviewed our database of patients with aneurysm from October 2013 to May 2016. Data were originally collected prospectively. The minisphenoidal approach has been progressively replacing the pterional approach for managing aneurysms in our department. Occlusion rates for ruptured and unruptured aneurysms were analyzed using late follow-up angiograms. Functional outcome assessment and the impact on quality of life were also measured.

RESULTS

We performed 124 minisphenoidal craniotomies in 117 patients to clip 147 aneurysms. Patient mean age was 53.9 years. Seventy patients (59.8%) presented with subarachnoid hemorrhage. Middle cerebral artery aneurysms represented 48% of the total number of aneurysms; posterior communicating artery aneurysms represented 24%. The minisphenoidal craniotomy was helpful in managing superior cerebellar artery aneurysms and 1 ruptured orbitofrontal artery aneurysm. We achieved an occlusion rate of 97.8%, with a mean follow-up of 13.2 months. Favorable outcomes were achieved for 79% of patients with subarachnoid hemorrhage and for 98% of unruptured patients.

CONCLUSIONS

Evolution of endovascular techniques has paved the way for minimizing surgical exposures. Routine use of the minisphenoidal approach for managing ruptured, unruptured, and previously coiled aneurysms is safe and provides adequate exposure with robust occlusion rates.

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.

Clipping of previously coiled cerebral aneurysms: efficacy, safety, and predictors in a cohort of 111 patients

OBJECTIVE With the increasing number of aneurysms treated with endovascular coiling, more recurrences are being encountered. The aim of this study was to evaluate the efficacy and safety of microsurgical clipping in the treatment of recurrent, previously coiled cerebral aneurysms and to identify risk factors that can affect the outcomes of this procedure. METHODS One hundred eleven patients with recurrent aneurysms whose lesions were managed by surgical clipping between January 2002 and October 2014 were identified. The rates of aneurysm occlusion, retreatment, complications, and good clinical outcome were retrospectively determined. Univariate and multivariate logistic regressions were performed to identify factors associated with these outcomes. RESULTS The mean patient age was 50.5 years, the mean aneurysm size was 7 mm, and 97.3% of aneurysms were located in the anterior circulation. The mean follow-up was 22 months. Complete aneurysm occlusion, as assessed by intraoperative angiography, was achieved in 97.3% of aneurysms (108 of 111 patients). Among patients, 1.8% (2 of 111 patients) had a recurrence after clipping. Retreatment was required in 4.5% of patients (5 of 111) after clipping. Major complications were observed in 8% of patients and mortality in 2.7%. Ninety percent of patients had a good clinical outcome. Aneurysm size (OR 1.4, 95% CI 1.08-1.7; p = 0.009) and location in the posterior circulation were significantly associated with higher complications. All 3 patients who had coil extraction experienced a postoperative stroke. Aneurysm size (OR 1.2, 95% CI 1.02-1.45; p = 0.025) and higher number of interventions prior to clipping (OR 5.3, 95% CI 1.3-21.4; p = 0.019) were significant predictors of poor outcome. An aneurysm size > 7 mm was a significant predictor of incomplete obliteration and retreatment (p = 0.018). CONCLUSIONS Surgical clipping is safe and effective in treating recurrent, previously coiled cerebral aneurysms. Aneurysm size, location, and number of previous coiling procedures are important factors to consider in the management of these aneurysms.

Retreatment of Recurrent Internal Carotid-Posterior Communicating Artery Aneurysm after Coil Embolization

Internal carotid-posterior communicating artery (IC-PC) aneurysms account for more than 20% of all intracranial aneurysms. As a result of the increase in coiling, there has also been an increase in recurrent IC-PC aneurysms after coiling. We present our experience of 10 recurrent IC-PC aneurysms after coiling that were retreated using surgical or endovascular techniques in order to discuss the choice of treatment and the points of clipping without removal of coils. From 2007 to 2014, 10 recurrent IC-PC aneurysms after coiling were retreated. When the previous frames covered the aneurysms all around or almost around except a part of the neck, coiling was chosen. In other cases, clipping was chosen. Clipping was attempted without removal of coils when it was technically feasible. Among the 10 IC-PC aneurysms retreated, 3 were retreated with coiling and 7 were retreated with clipping. In all three cases retreated with coiling, almost complete occlusion was accomplished. In the seven cases retreated with clipping, coil extrusion was observed during surgery in six cases. In most of them, it was necessary to dissect strong adhesions around the coiled aneurysms and to utilize temporary occlusion of the internal carotid artery. In all seven cases, neck clipping was accomplished without the removal of coils. There were no neurological complications in any cases. The management of recurrent lesions of embolized IC-PC aneurysms requires appropriate choice of treatment using both coiling and clipping. Clipping, especially without the removal of coils, plays an important role in safe treatment.