Timing of retreatment for patients with previously coiled or clipped intracranial aneurysms: Analysis of 156 patients with multiple treatments

Can further subdivision of the Raymond-Roy classification of intracranial aneurysms be useful in predicting recurrence and need for future retreatment following endovascular coiling?

Background:

The Raymond-Roy classification has been the standard for neck recurrences following endovascular coiling with three grades. Several modified classification systems with subdivisions have been reported in literature but it is unclear whether this adds value in predicting recurrence or retreatment. Our aim is to assess if these subdivisions aid in predicting recurrence and need for retreatment.

Methods:

A retrospective review of all patients undergoing endovascular coiling between 2013 and 2014. Patients requiring stent assistance or other embolization devices were excluded from the study. The neck residue was graded at time of coiling on the cerebral angiogram and subsequent 6, 24, and 60 months MRA. Correlation between grade at coiling and follow-up with need for subsequent retreatment was assessed.

Results:

Overall, 17/200 (8.5%) cases required retreatment within 5 years of initial coiling. 4/130 (3.1%) required retreatment within 5 years with initial Grade 0 at coiling, 6/24 cases (25%) of those Grade 2a, 4/20 cases (20%) Grade 2b, 3/8 (38%) Grade 3, and none of those with Grade 1. Large aneurysms ≥11 mm had an increased risk of aneurysm recurrence and retreatment. About 9.7% of ruptured aneurysms required retreatment versus 4.4% for unruptured. About 55% of carotid ophthalmic aneurysms were retreated.

Conclusion:

Although the modified classification system was significantly predictive of progressive recurrence and need for retreatment, no significant difference between the subdivisions of Grade 2 was observed. Similar predictive value was seen when using the Raymond-Roy classification compared to the new modified, limiting the usefulness of the new system in clinical practice.

The Hydrogel Endovascular Aneurysm Treatment Trial (HEAT): A Randomized Controlled Trial of the Second-Generation Hydrogel Coil

BACKGROUND

Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm.

OBJECTIVE

To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT).

METHODS

HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up.

RESULTS

A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms.

CONCLUSION

Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms.

VIDEO ABSTRACT

Outcome of retreatment for recurrent saccular cerebral aneurysms: a propensity score-matched analysis

Although endovascular or surgical treatment has been performed for preventing the rupture of saccular cerebral aneurysms (sCA), in some patients, the aneurysms may recur and require retreatment. We aimed to investigate the clinical and radiological outcomes of treating recurrent sCA. We retrospectively evaluated the data of 52 patients with 60 recurrent sCAs who were retreated and 1534 patients with 1817 sCAs who received initial treatment. The primary outcome was a recurrence of the aneurysm. Secondary outcomes were an additional treatment, rupture after treatment, and a neurological worsening, which was defined as an increase of 1 or more scores using the modified Rankin Scale at 12-month. Safety outcomes included postoperative ischemic and hemorrhagic complications. We compiled the 120 (60 each) propensity score-matched cohort based on a propensity score for the treatment of recurrent sCA. In the propensity score-matched cohort, recurrence after treatment was observed in 25% and 6.7% of cases in the retreatment and initial treatment groups, respectively. The odds ratio of recurrence after treatment was 4.7 (95% CI, 1.4-15; P = 0.011). The secondary and safety outcomes were not significantly different between the two groups. This study showed that the treatment of recurrent sCA was a risk factor for recurrence after treatment but not for additional treatment, rupture after treatment, or neurological worsening. Although decision-making regarding the treatment varies depending on the institutional protocols and personal experience of the physicians, endovascular or surgical retreatment could be performed without hesitation.

Treatment of Recurrent Intracranial Aneurysms After Neck Clipping: Novel Classification Scheme and Management Strategies

BACKGROUND

Recurrent aneurysms after initial clipping have been discussed as an important issue in the surgical management of aneurysm.

OBJECTIVE

To report our experience with recurrent cerebral aneurysms after neck clipping and to discuss classification and recommended management.

METHODS

Aneurysm treatments from a single institution over a 20-year period were retrospectively reviewed. Twenty-three recurrent aneurysms in 23 patients were managed during the study period. Recurrent aneurysms were classified using the concepts of closure line and closure plane, as follows. Type 1: neck situated in an almost different site from the previous clip. Type 2: existing closure plane and reconstructive closure plane are almost the same. Type 3: existing closure plane and reconstructive closure plane cross (type 3a); in rare cases, the existing closure line is sufficiently distant from the neck (type 3b). Type 4: no reconstructive closure line is identifiable.

RESULTS

Nine patients presented with subarachnoid hemorrhage at recurrence. The mean interval to recurrence was 15.0 years. Management comprised clipping with elective subsequent old-clip removal (n = 7), clipping with preceding old-clip removal (n = 2), bypass occlusion (n = 1), coating (n = 1), combined surgery (n = 1), endovascular surgery (n = 4), and observation (n = 3). Therapeutic intervention was not indicated in 4 patients. Types 3a and 4 required more complex surgical procedures or coil embolization. Procedural complications were observed in 2 patients.

CONCLUSION

A small but definite propensity toward recurrence after neck clipping exists, and most recurrent aneurysms require some form of retreatment. The novel classification scheme may provide conceptual clarity and therapeutic guidance for decision making.