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

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.

Surgical Treatment of Recurrent Previously Coiled and/or Stent-Coiled Intracerebral Aneurysms: A Single-Center Experience in a Series of 75 Patients

BACKGROUND

Endovascular treated cerebral aneurysms have a greater recurrence rate compared with microsurgical clip ligation. Despite recent endovascular advances, microsurgical clip ligation might be the treatment of choice for certain previously endovascular treated recurrent aneurysms. We report on our single-center experience with 76 previously coiled and/or stent-coiled aneurysms.

OBJECTIVE

To analyze the surgical and radiologic outcome after clipping of previous endovascular treated recurrent cerebral aneurysms.

METHODS

Patients were retrospectively identified. Demographic data, aneurysm size, location, perioperative coil extraction, occlusion rate, and complication rate were recorded. Patients were divided into a previously coiled-only group (COG) and a previously stent-assisted coiled group (SAC).

RESULTS

Seventy-five patients with 76 aneurysms were included. Sixty-nine patients were included in the COG, 7 patients in the SAC group. Complete or acceptable near-complete occlusion was obtained in 95% of patients in the COG and 57% in the SAC group. Two patients in the COG (2.9%) died postoperatively of a major stroke. One patient died of rehemorrhage after wrapping of an aneurysm. Minor complications occurred in 8.7%. In the SAC group, the mortality was 0%, with 1 major stroke (14.2%), 1 minor stroke (14.2%), and 1 cranial nerve palsy (14.2%). Intraoperative coil extraction and previous stent-assisted coiling were significant predictors of complication rate (P = 0.025 and P = 0.0036 respectively). Previous stent-assisted coiling was a significant predictor of incomplete occlusion (P = 0.036).

CONCLUSIONS

Microsurgical clipping of previously endovascular treated recurrent aneurysms is an effective treatment with high obliteration rates. Previously stent-assisted coiling and intraoperative coil extraction are predictors of worse outcome and incomplete occlusion.

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.