Microsurgical ligation for incompletely coiled or recurrent intracranial aneurysms: a 17-year single-center experience

Abstract

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.

Keywords: Coiled aneurysms; Endovascular coiling; Microsurgical clipping; Recurrent aneurysms.

Fig. 1

Patient 1. A 47-year-old woman presented with a ruptured right MCA aneurysm (a, b). She was initially treated with endovascular coiling, and the aneurysm was completely obliterated (c). The follow-up DSA revealed an aneurysm recurrence 36 months after initial coil embolization (d). She was treated with microsurgical clipping and total coil removal. Postoperative DSA showed complete obliteration of the recurrent aneurysm (e, f)

Fig. 2

Patient 2. A 12-year-old boy presented with a ruptured left ACA-A1 aneurysm (a, b). Complete obliteration was achieved after initial coiling (c, d). The follow-up DSA showed an aneurysm recurrence 3 months after initial coiling (e, f)

Fig. 3

Patient 2. Coil compaction was observed during surgery (a). The aneurysm was successfully clipped and the coiled mass was totally removed (b-d). Postoperative DSA revealed complete obliteration of the recurrent aneurysm (e, f)

Fig. 4

Patient 5. A 3-year-old boy presented with an unruptured left MCA aneurysm (a, b). The aneurysm was completely obliterated after initial coiling (c, d). The follow-up DSA showed an aneurysm recurrence 11 months after initial coiling (e, f). At the same time, the recurrent aneurysm was completely obliterated with recoiling (g). Three and a half months after recoiling, follow-up DSA showed a second recurrence of the coiled aneurysm (h)

Fig. 5

Patient 5. Coil compaction was observed during surgery (a). The aneurysm was successfully occluded and the coiled mass was totally removed (b-d)

Fig. 6

Patient 7. A 33-year-old man presented with a recurrent aneurysm 15 months after initial coiling (a, b). The coiled mass was completely removed (c, d). Coil extrusion through the aneurysm wall (c) and coil compaction (d) can be seen. Postoperative follow-up DSA showed complete obliteration of the recurrent aneurysm (e, f)

Fig. 7

Patient 28. A 16-year-old woman presented with a ruptured right posterior communicating artery aneurysm (a, b). The aneurysm was completely obliterated with initial coiling (c). The follow-up DSA showed aneurysm recurrence 12 months after initial coiling (d). Microsurgical clipping without coil removal and postoperative DSA showed complete obliteration of the recurrent aneurysm (e, f)

Fig. 8

Patient 47. A 62-year-old woman presented with an unruptured AcomA aneurysm (a, b). Complete obliteration was achieved after initial coiling (c, d). The patient experienced visual failure 9 months after initial coiling and DSA showed an aneurysm recurrence (e, f)

Fig. 9

Intraoperative results of patient 47. Coil extrusion can be observed during surgery (a–c). The optic chiasm was severely compressed by the coiled mass (a–c). After exposure and control of the proximal and distal vessels of the aneurysm, careful dissection was performed to free the coiled mass from surrounding structures. The coiled mass was transected (d, e) and half of the coiled mass was removed. (f) The residual half of coiled mass become more mobile and there was adequate neck for clipping. After clipping with one clip, the residual half of coiled mass was removed (g, h). Another clip was placed next to the first clip (i)