Combined endovascular and microsurgical procedures as complementary approaches in the treatment of a single intracranial aneurysm

Abstract

Objective: Both endovascular coil embolization and microsurgical clipping are now firmly established as treatment options for the management of cerebral aneurysms. Moreover, they are sometimes used as complementary approaches each other. This study retrospectively analyzed our experience with endovascular and microsurgical procedures as complementary approaches in treating a single aneurysm.

Methods: Nineteen patients with intracranial aneurysm were managed with both endovascular and microsurgical treatments. All of the aneurysms were located in the anterior circulation. Eighteen patients presented with SAH, and 14 aneurysms had diameters of less than 10 mm, and five had diameters of 10-25 mm.

Results: Thirteen of the 19 patients were initially treated with endovascular coil embolization, followed by microsurgical management. Of the 13 patients, 9 patients had intraprocedural complications during coil embolization (intraprocedural rupture, coil protrusion, coil migration), rebleeding with regrowth of aneurysm in two patients, residual sac in one patient, and coil compaction in one patient. Six patients who had undergone microsurgical clipping were followed by coil embolization because of a residual aneurysm sac in four patients, and regrowth in two patients.

Conclusion: In intracranial aneurysms involving procedural endovascular complications or incomplete coil embolization and failed microsurgical clipping, because of anatomical and/or technical difficulties, the combined and complementary therapy with endovascular coiling and microsurgical clipping are valuable in providing the best outcome.

Keywords: Cerebral aneurysm; Clipping; Coil embolization; Complementary therapy.

Fig. 1

Case 6. A 39-year-old man after subarachnoid hemorrhage from a right posterior communicating artery aneurysm. A: Right internal carotid artery angiogram demonstrating a 4×2 mm posterior communicating artery aneurysm. B: Angiographic image obtained with an injection through the guiding catheter in the right internal carotid artery demonstrating filling of the aneurysm neck and extravasation of contrast material. C: During further insertion of an additional coil, a stretched coil extending from the coil pack into the more distal internal carotid artery and extravasation of contrast material can be seen. D: Postoperative right internal carotid angiogram: the stretched coil was removed, and the aneurysm was clipped beneath the coil mass.

Fig. 2

Case 10. A 51-year-old man after subarachnoid hemorrhage from an anterior communicating artery aneurysm. A: Angiographic image obtained with an injection through the guiding catheter in the left internal carotid artery undergoing endovascular coil embolization. B: A coil mass has migrated into the callosomarginal branch of the anterior cerebral artery (arrow), although the patient was neurologically intact. C: The patient underwent aneurysm clipping without coil removal (arrow), because he had no neurological deficit.

Fig. 3

Case 15. A 70-year-old woman who had had a posterior communicating artery aneurysm clipped 14 years prior to presenting with a recurrent aneurysm. A: Left internal carotid angiogram showing a 6×4 mm aneurysm sac. B: Left internal carotid angiogram after clipping of the aneurysm shows the residual aneurysm sac. C: Left internal carotid angiogram after placement of coils within the residual aneurysm sac, achieving complete occlusion.