Factors affecting recurrence and management of recurrent cerebral aneurysms after initial coiling

Abstract

Objective: To investigate factors affecting recurrence and effects and safety of endovascular retreatment for aneurysms recurrent after embolization.

Methods: Among 815 aneurysms treated with embolization, recurrence was in 114 aneurysms (14.0%). Forty-three recurrent aneurysms were managed with re-embolization. Procedural complications, angiographic, and clinical results of retreatment were analyzed.

Results: Patients with recurrent aneurysms were significantly (P < 0.01) younger than without recurrence (51.09 ± 10.46 vs. 53.88 ± 9.61 years). Recurrent aneurysms (n = 114) were significantly (P = 0.00) greater (11.12 ± 8.35 vs. 5.81 ± 3.44 mm) with a significantly (P = 0.00) greater neck (4.34 ± 2.26 vs. 2.90 ± 1.44 mm) than without recurrence. The rupture status of aneurysms significantly (P = 0.00) affected recurrence at follow-up. Significantly (P = 0.00) more aneurysms without recurrence were treated with advanced embolization techniques (81.0% vs. 62.3%) and got complete occlusion at the first embolization than those with recurrence (93.7% vs. 36.8%). In treating 43 recurrent aneurysms, stent-assisted recoiling was used in 48.8% in the first retreatment and 50% in the second and third retreatment procedures. Angiographic follow-up in 38 (88.4%) cases showed complete or near complete occlusion in 30 aneurysms, with the rest eight aneurysms experiencing a second recurrence (21.1%). Of the eight aneurysms with the second recurrence, five underwent the second endovascular retreatment, with complete aneurysm occlusion achieved in three cases (60%), near-complete occlusion in one (20%), and incomplete occlusion in one case at immediate angiography and six-month follow-up. Procedure-related complications occurred in three patients.

Conclusions: Endovascular retreatment of recurrent previously coiled aneurysms is safe and effective even though advanced embolization techniques are frequently involved especially for large and giant aneurysms.

Keywords: Cerebral aneurysm; embolization; endovascular retreatment; pipeline embolization device; recurrence.

Figure 1.

A 53-year-old woman had a giant aneurysm at the ophthalmic segment of the left ICA and was treated using stent-assisted coiling three times. (a) Left ICA angiography showed a giant aneurysm at the ophthalmic artery segment. (b) Immediately following endovascular embolization with the stent-assisted coiling, near-complete occlusion of the aneurysm was achieved. (c) Follow-up angiography nine months after the first embolization revealed coil compaction and recanalization at the aneurysm neck. (d) At the end of the second embolization still with the stent-assisted coiling, the aneurysm was occluded near completely. (e) Follow-up angiography eight months later demonstrated recurrence at the aneurysm neck. (f) The third stent-assisted coiling was performed, and the aneurysm was occluded near completely. (g) Angiogram four months after the third embolization revealed near complete occlusion. (h) Angiogram obtained 12 months after the third embolization indicated total occlusion. ICA: internal carotid artery.

Figure 2.

A 46-year-old woman had sudden headache for 3 h. (a) Head computed tomography showed subarachnoid hemorrhage. (b) Cerebral angiography revealed an aneurysm at the left ophthalmic segment of the internal carotid artery measuring 15.0 × 16.3 mm with a neck size of 7.3 mm. (c) The patient was treated with enterprise stent-assisted coiling using dual microcatheters. The two arrows showed the tips of the dual microcatheters. (d) Immediately following embolization, the aneurysm was completely occluded. (e) At follow-up six months later, the aneurysm was recurrent due to coil compaction. (f) Re-embolization was performed with the enterprise stent-assisted coiling and the aneurysm was completely occluded. (g) At six months after the re-embolization, the aneurysm remained totally occluded. (h) At four years, the aneurysm remained completely occluded.

Figure 3.

(a) Follow-up angiography at six months showed coil compaction and recurrence of the aneurysm at the Pcom of the left ICA. (b) At second embolization, a single PED was implanted. (c) Immediate postembolization angiography showed contrast agent retention within the aneurysm cavity. (d) Right ICA angiogram at 12 months after the PED procedure demonstrated the right anterior and middle cerebral arteries were supplied from the contralateral ICA via the anterior communicating artery. (e) Left ICA angiogram revealed near-total aneurysm occlusion. ICA: internal carotid artery; Pcom: posterior communicating artery; PED: pipeline embolization device.