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da Silva Júnior NR, Trivelato FP, Nakiri GS, Rezende MTS, de Castro-Afonso LH, Abud TG, Vanzin JR, Manzato LB, Ulhôa AC, Abud DG, Giannetti AV. Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping. J Cerebrovasc Endovasc Neurosurg 2021; 23:221-232. [PMID: 34470100 PMCID: PMC8497721 DOI: 10.7461/jcen.2021.e2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/19/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Total aneurysm occlusion is crucial for the prevention of rebleeding of a ruptured aneurysm or to avoid rupture of an unruptured lesion. Both surgical and endovascular embolization fail to achieve complete aneurysm occlusion in all the cases. The objective of the study was to establish the safety and efficacy of endovascular treatment for previously clipped residual or recurrent aneurysms. METHODS This was an observational, retrospective study of patients harboring incompletely occluded intracranial aneurysms after clipping who underwent endovascular treatment. Patients were treated using 4 different techniques: (1) simple coiling, (2) balloon remodeling, (3) stent-assisted coiling, and (4) flow diversion. Analyses were performed to identify predictors of total aneurysm occlusion, recanalization and complications. RESULTS Between May 2010 and September 2018, 70 patients harboring incompletely occluded intracranial aneurysms after clipping met the inclusion criteria in 5 centers. The mean residual aneurysm size was 7.5 mm. Fifty-nine aneurysms were unruptured. Total aneurysm occlusion was achieved in 75.3% of the aneurysms after 1 year. All aneurysms treated with flow diversion revealed complete occlusion according to control angiography. Recanalization was observed in 14.5%. Permanent morbidity and mortality occurred in 2.9% and 1.4% of the patients, respectively. CONCLUSIONS Endovascular treatment of recurrent or residual aneurysms after surgical clipping was safe and efficacious. Flow diversion seems to be associated with better anatomical results. A more rigid study, a larger group of patients, and longterm follow-up are required to provide stronger conclusions about the best approach for residual clipped aneurysms.
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Affiliation(s)
| | - Felipe Padovani Trivelato
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Luís Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- Division of Interventional Neuroradiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - José Ricardo Vanzin
- Division of Interventional Neuroradiology, Hospital de Clínicas, Passo Fundo, Rio Grande do Sul, Brazil
| | - Luciano Bambini Manzato
- Division of Interventional Neuroradiology, Hospital de Clínicas, Passo Fundo, Rio Grande do Sul, Brazil
| | - Alexandre Cordeiro Ulhôa
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Alexandre Varella Giannetti
- Department of Neurosurgery, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Tanaka R, Ansari A, Kato Y, Yamada Y, Kawase T, Kalyan S. Combined Endovascular and Microsurgical Hybrid Management of Cerebral Aneurysms: The Preliminary Fujita Experience. Asian J Neurosurg 2019; 14:863-867. [PMID: 31497115 PMCID: PMC6703050 DOI: 10.4103/ajns.ajns_133_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: A subgroup of complex aneurysms demands multimodal treatment by microscopic and endovascular means. Partial obliteration or remnant postprocedure demands to go further to the other modality. Materials and Methods: All patients between July 2016 and January 2017 who had to undergo multimodality measures for complete obliteration of the aneurysms were included in the study. The patients who had either undergone clipping or coiling for their aneurysms, but with incomplete obliteration of the aneurysm, were also included in the study. Results: Between July 2016 and January 2017, a total of three patients had to undergo coiling after clipping of the aneurysm for complete obliteration. Two patients had to go for clipping following coiling. All five patients had complete obliteration of the aneurysm sac. Conclusion: Both microscopic and endovascular means are complementary measures instead of competing procedures. It is important to realize the technical difficulties when surgical therapy follows initial endovascular treatment. Similarly, coiling a previously clipped aneurysm can be difficult, if the clip obscures normal working projections.
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Affiliation(s)
- Riki Tanaka
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Ahmed Ansari
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - T Kawase
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Sai Kalyan
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
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Yu LB, Fang ZJ, Yang XJ, Zhang D. Management of Residual and Recurrent Aneurysms After Clipping or Coiling: Clinical Characteristics, Treatments, and Follow-Up Outcomes. World Neurosurg 2019; 122:e838-e846. [DOI: 10.1016/j.wneu.2018.10.160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 10/27/2022]
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Kim ST, Baek JW, Jin SC, Park JH, Kim JS, Kim HY, Jeong HW, Jeong YG. Coil Embolization in Patients with Recurrent Cerebral Aneurysms Who Previously Underwent Surgical Clipping. AJNR Am J Neuroradiol 2018; 40:116-121. [PMID: 30573462 DOI: 10.3174/ajnr.a5909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/10/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Surgical revision of recurrent cerebral aneurysms is technically difficult. Therefore, coil embolization has been used as an alternative in these cases. The aim of this study was to evaluate the clinical and angiographic outcomes of coil embolization in patients with recurrent cerebral aneurysms after microsurgical clipping. MATERIALS AND METHODS Between May 1999 and February 2016, nineteen patients with 19 recurrent aneurysms who previously underwent surgical clipping were treated by coil embolization. RESULTS Nine patients presented with subarachnoid hemorrhage (47.4%). The interval between surgical clipping and coil embolization was 143.5 ± 66.1 months (range, 43-276 months). Single- or double-catheter coil embolization was performed in 16 patients. A balloon (n = 1) and stents (n = 2) were used to assist the coil embolization in 3 patients. Immediate radiologic findings after coil embolization showed complete occlusion in 10 patients, a residual neck in 8 patients, and a residual sac in 1 patient. Procedure-related permanent morbidity occurred in 1 patient. The mean clinical follow-up was 58.3 ± 38.8 months. Poor clinical outcomes (modified Rankin Scale score = ≥3) at the end of the clinical follow-up were reported in 5 patients (26.3%). Angiographic follow-up was available for 12 patients (63.2%). Major recurrence was detected in 5 patients (41.7%), and a tendency for aneurysm regrowth rather than coil compaction was noted in all cases. CONCLUSIONS In our series, coil embolization for recurrent aneurysms after surgical clipping was feasible but had a high recurrence rate and tended to result in aneurysm regrowth rather than coil compaction.
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Affiliation(s)
- S-T Kim
- From the Departments of Neurosurgery (S.-T.K., J.H.P., Y.G.J.)
| | - J W Baek
- Diagnostic Radiology (J.W.B., H.W.J.), Busan Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea
| | - S-C Jin
- Department of Neurosurgery (S.-C.J., J.S.K., H.Y.K.), Haeundae Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea.
| | - J H Park
- From the Departments of Neurosurgery (S.-T.K., J.H.P., Y.G.J.)
| | - J S Kim
- Department of Neurosurgery (S.-C.J., J.S.K., H.Y.K.), Haeundae Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea
| | - H Y Kim
- Department of Neurosurgery (S.-C.J., J.S.K., H.Y.K.), Haeundae Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea
| | - H W Jeong
- Diagnostic Radiology (J.W.B., H.W.J.), Busan Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea
| | - Y G Jeong
- From the Departments of Neurosurgery (S.-T.K., J.H.P., Y.G.J.)
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Muskens IS, Hertgers O, Lycklama à Nijeholt GJ, Broekman MLD, Moojen WA. Outcomes of Retreatment for Intracranial Aneurysms — A Meta-Analysis. Neurosurgery 2018; 85:750-761. [DOI: 10.1093/neuros/nyy455] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 09/12/2018] [Indexed: 12/21/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Ivo S Muskens
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- Center for Genetic Epidemiology, Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Omar Hertgers
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Brain Center Rudolf Magnus University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wouter A Moojen
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
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Romagna A, Ladisich B, Schwartz C, Winkler PA, Rahman ASA. Flow-diverter stents in the endovascular treatment of remnants in previously clipped ruptured aneurysms: a feasibility study. Interv Neuroradiol 2018; 25:144-149. [PMID: 30370818 DOI: 10.1177/1591019918805774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The rate of intracranial aneurysm remnants/recurrences after microsurgical clipping varies widely. The optimal management for these patients remains a matter of debate. Repeat surgery in particular bears a high risk of periprocedural complications due to anatomical distortion from prior procedures. This study aims to evaluate the risk-benefit profile of flow-diverter stents in these patients. METHODS The patient database of our neurovascular centre was queried to identify patients with clipped aneurysms who subsequently underwent endovascular treatment with intraluminal flow-diverter stents. The outcome analysis consisted of an assessment of clinical parameters (modified Rankin scale) and the post-interventional angiographic occlusion status (according to the Raymond-Roy occlusion classification). RESULTS Six patients underwent endovascular treatment with flow-diverter stents of recurrent aneurysms after clipping. Treatment was necessary in two patients due to progressive neurological deficits, and due to angiographic proof of an increasing aneurysm size in the other four patients. Median aneurysm size was 0.45 cm. All patients had a prior history of subarachnoid haemorrhage. The time from primary clipping to recurrence was 10.6 years. Complete radiological aneurysm occlusion was feasible in five out of six cases. Two patients who had experienced pre-interventional neurological deficits showed a complete remission of symptoms on last follow-up. No periprocedural morbidity or mortality was recorded and no patient required retreatment within the median follow-up. CONCLUSION This case series suggests that endovascular treatment with flow-diverter stents of aneurysm remnants after previous microsurgical clipping is a feasible treatment concept with a low-risk profile, which might prevent the treatment burden and risks of repeat surgery.
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Affiliation(s)
- Alexander Romagna
- 1 Division of Neurosurgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (current address).,2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
| | - Barbara Ladisich
- 2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
| | - Christoph Schwartz
- 2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
| | - Peter A Winkler
- 2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
| | - Al-Schameri Abdul Rahman
- 2 Department of Neurosurgery, Christian Doppler Medical Center, Paracelsus Private Medical University, Salzburg, Austria
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Dimitriadis S, Qeadan F, Taylor CL, Yonas H, Carlson AP. Middle Cerebral Artery Aneurysm "Neck Overhang": Decreased Postclipping Residual Using the Intersecting Clipping Technique. Oper Neurosurg (Hagerstown) 2018. [PMID: 29529311 DOI: 10.1093/ons/opx278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Middle cerebral artery (MCA) aneurysms continue to be viewed by many as primarily surgical entities. OBJECTIVE To introduce a new, easily measurable dimension termed "neck overhang," defined as the amount of the aneurysm that extends proximal to the 2 dimensionally defined "neck" and to evaluate the utility of the intersecting clipping technique (use of straight clip and intersecting fenestrated clip) to adapt to this overhanging segment's specific dimensions and achieve better obliteration of the MCA aneurysms. METHODS We reviewed retrospectively 100 MCA aneurysms treated surgically over the last 10 yr at our institution. We identified the clipping technique that was performed (intersecting vs "standard" technique) and we evaluated the presence of a postoperative remnant. We then correlated these with the aneurysm's overhanging neck length. RESULTS Forty-three aneurysms were treated with the intersecting clipping technique. The overall rate of remnant was 16%. In the standard group, the rate of remnant was 23%, whereas with intersecting clipping that was 7% (P = .029). Within the standard clipping group, we found that the optimum threshold for length of the neck overhang was ≥1.9 mm in order to predict the occurrence of residual. Applying this threshold to the intersecting clipping technique group resulted in a reduction in remnant from 35% in the standard group to 9%. CONCLUSION Neck overhang >1.9 mm is associated with a higher chance of postclipping residual aneurysm in MCA aneurysms. The intersecting clipping technique is a versatile technique that can conform to various aneurysms' geometry and can reduce the rate of post clipping residual for aneurysms with high neck overhang.
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Affiliation(s)
- Stavros Dimitriadis
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Fares Qeadan
- Department of Internal Medicine, division of Epidemiology, Biostatistics and Preventive Medicine University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Christopher L Taylor
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Howard Yonas
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Andrew P Carlson
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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Schwartz C, Aster HC, Al-Schameri R, Müller-Thies-Broussalis E, Griessenauer CJ, Killer-Oberpfalzer M. Microsurgical clipping and endovascular treatment of middle cerebral artery aneurysms in an interdisciplinary treatment concept: Comparison of long-term results. Interv Neuroradiol 2018; 24:608-614. [PMID: 30071740 DOI: 10.1177/1591019918792231] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Treatment of middle cerebral artery (MCA) aneurysms has been historically considered as the almost exclusive domain of microsurgical clipping. This retrospective single-center study assesses whether microsurgical clipping or endovascular treatment (i.e. coiling and/or stenting) for MCA aneurysms yielded better occlusion rates and clinical outcome. METHODS We identified patients with a minimum clinical follow-up of 12 months who had undergone MCA aneurysm repair either by clipping or by endovascular treatment between 2005 and 2015. Aneurysm occlusion rates were assessed by the Raymond-Roy Occlusion Classification (RROC) and patients' clinical outcome was measured by the modified Rankin Scale (mRS). All patients had been treated in an interdisciplinary treatment concept at a large neurovascular center; both treatment modalities were available at all times. RESULTS Ninety-two eligible patients with MCA aneurysms, of whom 21.7% patients were treated for subarachnoid hemorrhages, were included; 38 patients underwent endovascular therapy and 54 clipping. The median age at treatment was 53.5 years (range, 25-79 years) and the median clinical follow-up was 98.5 months (range, 18-213 months). Occlusion rates were significantly higher in the clipping cohort (RROC = 1: 96.3% vs 78.9%; p = 0.04), long-term clinical outcome was better in the endovascular treatment cohort (mRS ≤ 1: 100.0% vs 90.8%; p < 0.01). Permanent treatment-associated morbidity was seen more commonly in the clipping cohort (9.3% vs 0.0%). CONCLUSIONS Both treatment modalities are associated with excellent clinical and radiological outcome if applied within an interdisciplinary treatment concept. Endovascular aneurysm repair appears to be an attractive treatment alternative compared to clipping with low complication rates for well-selected patients.
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Affiliation(s)
- Christoph Schwartz
- 1 Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Hans-Christoph Aster
- 2 Research Institute of Neurointervention, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Rahman Al-Schameri
- 1 Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | | | - Christoph J Griessenauer
- 2 Research Institute of Neurointervention, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria.,3 Department of Neurosurgery, Geisinger Health, Danville, PA, USA
| | - Monika Killer-Oberpfalzer
- 2 Research Institute of Neurointervention, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria.,3 Department of Neurosurgery, Geisinger Health, Danville, PA, USA
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9
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Safety and Efficacy of Endovascular Treatment of Previously Clipped Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 114:e137-e150. [DOI: 10.1016/j.wneu.2018.02.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 01/04/2023]
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10
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Chen K, Wang L, Wang D, Liu J, Lu J, Qi P. Balloon-in-stent assisted coiling for treatment of intracranial overwide and undertall aneurysms. J Clin Neurosci 2016; 34:202-206. [PMID: 27658574 DOI: 10.1016/j.jocn.2016.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 08/03/2016] [Accepted: 08/10/2016] [Indexed: 11/28/2022]
Abstract
This study reports our experience of balloon-in-stent assisted coiling for the treatment of morphologically unfavorable aneurysms located in the internal carotid artery (ICA). From July 2007 to April 2014, twelve patients with twelve aneurysms located in the ICA were coil embolized by simultaneously using balloon and stent assistance. Five aneurysms were ruptured and seven were unruptured. All the aneurysms were overwide (dome-to-neck ratio ⩽1.2) and undertall (aspect ratio ⩽1.2) anatomically. The procedure-related adverse events, clinical and angiographic results were retrospectively analyzed. Intraprocedural aneurysmal bleeding occurred for one unruptured aneurysm but was stopped immediately after the balloon was inflated. Periprocedural thromboembolism occurred for two ruptured aneurysms, leading to death in one patient and severe neurological deficit for the other one. Procedure-related permanent morbidity and mortality rates were 8.3% (1/12) and 8.3% (1/12). Satisfactory (total and subtotal) occlusion was obtained immediately in 11 (91.7%) cases. Nine aneurysms received digital subtraction angiography follow-up (mean 25.1months, range 6-55), and all of them except one were totally obliterated. No aneurysmal bleeding occurred during a mean period of 59.1months, clinical follow-up for eleven patients. Balloon-in-stent assisted coiling might be a therapeutic alternative to prevent growth or rupture of overwide and undertall aneurysms. Nevertheless, it should be used prudently for ruptured ICA aneurysms, for its disadvantage of technical complexity and relatively high rate of adverse events.
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Affiliation(s)
- Kunpeng Chen
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China; Beijing Institute of Geriatrics, Graduate School of Peking Union Medical College, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
| | - Lijun Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China; Beijing Institute of Geriatrics, Graduate School of Peking Union Medical College, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China.
| | - Jiachun Liu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
| | - Jun Lu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, China, No. 1 DaHua Road, Dong Dan, Beijing 100730, PR China
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Gross BA, Albuquerque FC, Moon K, Ducruet AF, McDougall CG. Endovascular treatment of previously clipped aneurysms: continued evolution of hybrid neurosurgery. J Neurointerv Surg 2016; 9:169-172. [DOI: 10.1136/neurintsurg-2016-012625] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 07/14/2016] [Accepted: 07/19/2016] [Indexed: 11/04/2022]
Abstract
Background/objectiveThe optimal management of residual or recurrent clipped aneurysms is infrequently addressed in the literature.MethodsWe reviewed our endovascular database from January 1998 to May 2016 to identify patients with clipped aneurysms undergoing subsequent endovascular treatment, evaluating treatment approach, and clinical and angiographic outcomes.Results60 patients underwent endovascular treatment of residual/recurrent clipped aneurysms; 7 rebled prior to endovascular therapy. Treatment was via coiling alone (n=25, 42%), stent assisted coiling (n=15, 25%), balloon assisted coiling (n=8, 13%), flow diversion (n=8, 13%), stenting alone (n=3, 5%), or flow diversion with coiling (n=1, 2%). The procedural permanent neurological morbidity and mortality rates were 3% and 2%, respectively. Over a clinical follow-up of 253.4 patient years (median 3.9 years), there was one rebleed in a patient who had declined further treatment. For 43 patients with at least 1 month of digital subtraction angiographic follow-up (median 3.4 years), complete aneurysm occlusion was seen in 79% of cases. Neck remnants were observed in 14%, and stable small dome remnants were observed in 7% of cases. In a subgroup of 18 patients with ‘clip induced’ narrow neck aneurysms, all domes were initially coil occluded (Raymond 1 or 2); there was no permanent procedural morbidity and no aneurysms required retreatment or recanalized over a median follow-up of 3.9 years.ConclusionsEndovascular treatment of residual or recurrent clipped aneurysms is an excellent treatment approach in well selected patients; ‘clip induced’ narrow neck aneurysms fare particularly well after treatment both angiographically and clinically.
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12
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Hokari M, Kazumara K, Nakayama N, Ushikoshi S, Sugiyama T, Asaoka K, Uchida K, Shimbo D, Itamoto K, Yokoyama Y, Isobe M, Imai T, Osanai T, Houkin K. Treatment of Recurrent Intracranial Aneurysms After Clipping: A Report of 23 Cases and a Review of the Literature. World Neurosurg 2016; 92:434-444. [PMID: 27241096 DOI: 10.1016/j.wneu.2016.05.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/16/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE There are no established treatment strategies for aneurysms that recur after clipping. In this study, we present cases of patients who experienced recurrent aneurysms after clipping and subsequently underwent surgical intervention. METHODS Between 2004 and 2015, we surgically treated 23 aneurysms that recurred at a previously clipped site. Patient characteristics and clinical history were retrospectively reviewed. RESULTS Patients included 19 women and 4 men 45-81 years old. Aneurysms recurred 3-31 years (mean, 15.4 years) after the initial operation. For 18 cases, the first clinical presentation was a subarachnoid hemorrhage; aneurysms were incidentally diagnosed in 5 patients. Aneurysm locations were as follows: 9 on the internal carotid artery; 4 on the middle cerebral artery; 7 on the anterior communicating artery; 2 on the distal anterior cerebral artery; and 1 on the basilar artery. The reasons for retreatment included subarachnoid hemorrhage (n = 9) and aneurysm regrowth detected on follow-up examinations (n = 14). Endovascular treatment was performed in 10 cases, and direct surgery was performed in 13 cases (clipping in 8, clipping or trapping with bypass in 5). Various complex vascular reconstructions, including high-flow bypass and intracranial-intracranial in situ bypass, were performed for recurrent aneurysms. CONCLUSIONS In our experience, coil embolization is a safe and effective procedure for treating recurrent aneurysms. When cases are unsuitable for coil embolization, surgical treatment often requires neurosurgeons not only to overcome the general technical difficulty of reoperative clipping but also to perform challenging vascular reconstruction.
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Affiliation(s)
- Masaaki Hokari
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan; Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.
| | - Ken Kazumara
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Naoki Nakayama
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Satoshi Ushikoshi
- Department of Neurosurgery, National Hospital Organization Hokkaido Medical Center, Sapporo, Hokkaido, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Katsunori Asaoka
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kazuki Uchida
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Daisuke Shimbo
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Koji Itamoto
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Yuka Yokoyama
- Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Masanori Isobe
- Department of Neurosurgery, Kushiro Rosai Hospital, Kushiro, Hokkaido, Japan
| | - Tetsuaki Imai
- Department of Neurosurgery, Kushiro Rosai Hospital, Kushiro, Hokkaido, Japan
| | - Toshiya Osanai
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
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Ideal clipping methods for unruptured middle cerebral artery bifurcation aneurysms based on aneurysmal neck classification. Neurosurg Rev 2015; 39:215-23; discussion 223-4. [DOI: 10.1007/s10143-015-0671-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 06/16/2015] [Accepted: 06/27/2015] [Indexed: 10/23/2022]
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14
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Abstract
As neuroendovascular interventions for both ruptured and unruptured intracranial aneurysms have come to the forefront, careful follow-up and strategies for retreatment of aneurysmal recurrences have become increasingly important. Endovascular approaches have also proven to be valuable adjuncts for managing recurrent aneurysms previously treated by open microsurgical approaches. Fortunately, retreatment of recurrent aneurysms can be performed safely, and the use of stents during retreatment has increased the proportion of durably retreated aneurysms. More recently, the spectrum of recurrent aneurysms readily amenable to endovascular therapy has been expanded by the widespread introduction of flow diverters.
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Li K, Cho YD, Kang HS, Kim JE, Han MH, Lee YM. Endovascular management for retreatment of postsurgical intracranial aneurysms. Neuroradiology 2013; 55:1345-53. [PMID: 23949553 DOI: 10.1007/s00234-013-1270-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 08/06/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Incomplete surgical treatment of intracranial aneurysms and recurrent postsurgical aneurysms are associated with a risk of rebleeding, and additional treatment is generally recommended. Surgical retreatment may carry a risk of procedural complications due to technical difficulty. We present here our experience with the endovascular approach for the retreatment of intracranial aneurysms that were initially treated with open surgery. METHODS From January 2002 through January 2013, a total of 43 patients with 43 postsurgical index aneurysms were identified and underwent subsequent endovascular treatment. Clinical and radiological data were retrospectively reviewed. RESULTS Thirty-one patients were surgically clipped before endovascular coiling and 12 patients were nonclipped, which included wrapping. Hemorrhagic presentation occurred in 21 patients prior to coiling. The interval between the initial surgical treatment and coiling varied from 0 days to 264 months (median, 9 months). Endovascular coiling resulted in the successful occlusion of 36 aneurysms (84 %). Procedure-related complications included asymptomatic thrombus formation in six patients, symptomatic cerebral infarction in two patients, and retroperitoneal hemorrhage in one patient. Delayed cerebral infarction occurred in two patients with a deployed stent. The procedure-related permanent morbidity and mortality rates were 6.9 and 0 %, respectively. Radiological follow-up evaluations beyond 6 months were available in 26 patients (60 %), which revealed major recanalization in three patients (11.5 %). There was no rebleeding during the follow-up period, which ranged from 3 to 115 months (mean, 34.5 months). CONCLUSION Endovascular embolization may serve as a safe, efficacious, and durable treatment option in the management of postsurgical intracranial aneurysms.
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Affiliation(s)
- Ke Li
- Department of Interventional Radiology, 1st Affiliated Hospital of Dalian Medical University, Dalian, China
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16
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Choudhri O, Mukerji N, Steinberg GK. Combined endovascular and microsurgical management of complex cerebral aneurysms. Front Neurol 2013; 4:108. [PMID: 23964263 PMCID: PMC3737456 DOI: 10.3389/fneur.2013.00108] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 07/19/2013] [Indexed: 12/15/2022] Open
Abstract
Cerebral aneurysms are associated with a 50% mortality rate after rupture and patients can suffer significant morbidity during subsequent treatment. Neurosurgical management of both ruptured and unruptured aneurysms has evolved over the years. The historical practice of using microsurgical clipping to treat aneurysms has benefited in the last two decades from tremendous improvement in endovascular technology. Microsurgery and endovascular therapies are often viewed as competing treatments but it is important to recognize their individual limitations. Some aneurysms are considered complex, due to several factors such as aneurysm anatomy and a patient’s clinical condition. A complex aneurysm often cannot be completely excluded with a single approach and its successful treatment requires a combination of microsurgical and endovascular techniques. Planning such an approach relies on understanding aneurysm anatomy and thus should routinely include 3D angiographic imaging. In patients with ruptured aneurysms, endovascular coiling is a well-tolerated early treatment and residual aneurysms can be treated with intervals of definitive clipping. Microsurgical clipping also can be used to reconstruct the neck of a complex aneurysm, allowing successful placement of coils across a narrow neck. Endovascular techniques are assisted by balloons, which can be used in coiling and testing parent vessel occlusion before sacrifice. In some cases microsurgical bypasses can provide alternate flow for planned vessel sacrifice. We present current paradigms for combining endovascular and microsurgical approaches to treat complex aneurysms and share our experience in 67 such cases. A dual microsurgical–endovascular approach addresses the challenge of intracranial aneurysms. This combination can be performed safely and produces excellent rates of aneurysm obliteration. Hybrid angiographic operating-room suites can foster seamless and efficient complementary application of these two modalities.
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Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery, Stanford Stroke Center, Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine , Stanford, CA , USA
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Tähtinen OI, Manninen HI, Vanninen RL, Rautio R, Haapanen A, Seppänen J, Niskakangas T, Rinne J, Keski-Nisula L. Stent-assisted embolization of recurrent or residual intracranial aneurysms. Neuroradiology 2013; 55:1221-31. [DOI: 10.1007/s00234-013-1234-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/01/2013] [Indexed: 11/29/2022]
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Spiotta AM, Hui F, Schuette A, Moskowitz SI. Patterns of aneurysm recurrence after microsurgical clip obliteration. Neurosurgery 2013; 72:65-9; discussion 69. [PMID: 23096416 DOI: 10.1227/neu.0b013e318276b46b] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Microsurgical clip obliteration remains a time-honored and viable option for the treatment of select aneurysms with very low rates of recurrence. OBJECTIVE We studied previously clipped aneurysms that were found to have recurrences to better understand the patterns and configurations of these rare entities. METHODS A retrospective review was performed of 2 prospectively maintained databases of aneurysm treatments from 2 institutions spanning 14 years to identify patients with recurrence of previously clipped intracranial aneurysms. RESULTS Twenty-six aneurysm recurrences were identified. Three types of recurrence were identified: type I, proximal to the clip tines; type II, distal; and type III, lateral. The most common type of recurrence was that arising distal to the clip tines (46.1%), and the least frequently encountered recurrence was that arising proximal to the tines (19.2%). Laterally located recurrences were found in 34.6% of cases. CONCLUSION We describe 3 different patterns of aneurysm recurrence with respect to clip application: those occurring proximal, distal, or lateral to the clip tines.
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Affiliation(s)
- Alejandro M Spiotta
- Division of Neurosurgery, Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Kim ST, Jeong HW, Jeong YG, In HS. Coiling as Retreatment in Intracranial Aneurysm of de novo Formation or Regrowth: Case Report. Neurointervention 2013; 8:46-51. [PMID: 23515648 PMCID: PMC3601281 DOI: 10.5469/neuroint.2013.8.1.46] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 02/05/2013] [Indexed: 11/25/2022] Open
Abstract
Development of de novo aneurysm or aneurysm regrowth after complete clipping of an intracranial aneurysm is rare. We report coiled cases of de novo aneurysm and aneurysm regrowth. We retrospectively reviewed 107 cases of intracranial aneurysm coiling performed in our hospital, identifying five cases of coiled aneurysm that were de novo aneurysm or aneurysm regrowth. In all the cases, total or near total occlusion was seen. There were no complications related to the procedure. In two of the three patients with ruptured aneurysms, consciousness level on admission was stupor. When the patient was discharged after the treatment, one of them had 4 of the modified Rankin Scale. The other one had 5 on discharge. The rest three patients had 0. As for a de novo aneurysm or a regrowth of aneurysm, coiling may be considered when clipping is difficult.
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Affiliation(s)
- Sung Tae Kim
- Department of Neurosurgery, Busan Paik Hospital, Inje University, Busan, Korea
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