Microsurgical management of previously embolized intracranial aneurysms: A single center experience and literature review

Abstract

Background: Endovascular treatment of intracranial aneurysms (IAs) provides less invasiveness and lower morbidity than microsurgical clipping, albeit with a long-term recurrence rate estimated at 20%. We present our single-center experience and a literature review concerning surgical clipping of recurrent previously coiled aneurysms.

Methods: Retrospective analysis of nine (9) patients' data and final clinical/angiographic outcomes, who underwent surgical clipping of IAs in our center following initial endovascular treatment, over a 12-year period (2010-2022). Regarding the literature review, data were extracted from 48 studies including 969 patients with 976 aneurysms.

Results: 9 patients (5 males - 4 females) were included in the study with a mean age of 49 years. Subarachnoid hemorrhage was the initial presentation in 78% of patients. Aneurysms' most common location was the middle cerebral artery bifurcation (5/9) followed by the anterior communicating artery (3/9) and the internal carotid artery bifurcation (1/9). Indications for surgery were coil loosening, coil compaction, sac regrowth, and residual neck. Procedure-related morbidity and mortality were zero whereas complete aneurysm occlusion was achieved after surgical clipping in all cases (100%). All patients had minimal symptoms or were asymptomatic (mRS 0-1) at the final follow-up.

Conclusions: Surgical clipping seems a feasible and safe technique for selected cases of recurrent previously coiled intracranial aneurysms. A universally accepted recurrence classification system and a guideline template for the management of such cases are needed.

Keywords: Endovascular embolization; Intracranial aneurysm; Microsurgery; Microsurgical clippin; Recurrence.

Fig. 1.

Pre- vs Postoperative neurological status of the 9 patients that were treated in our center. mRS, modified Rankin Scale

Fig. 2.

Indications for microsurgical treatment of 957 previously coiled aneurysms.

Fig. 3.

Use of the different surgical strategies in the treatment of 976 previously coiled aneurysms.

Fig. 4.

Post-operative outcome of 868 patients classified as Good (GOS 4-5, mRS 0-2) Bad (GOS 2-3, mRS 3-5) and Death (GOS 1, mRS 6). GOS, Glasgow Outcome Scale; mRS, modified Rankin Scale

Fig. 5.

Pre- vs Postoperative outcome of 420 patients classified as Good (GOS 4-5, mRS 0-2) Bad (GOS 2-3, mRS 3-5) and Death (GOS 1, mRS 6). GOS, Glasgow Outcome Scale; mRS, modified Rankin Scale

Fig. 6.

(A) DSA illustrates a ruptured narrow neck ACoA aneurysm (white arrow). (B) Complete embolization of the aneurysm has been initially performed (white arrow). (C) FU angiogram shows recanalization of the neck (red arrow). (D) Intraoperative view illustrates the neck remnant. (E) A 45° angled clip has been placed below the coil mass (white arrow). (F, G) Postopetrative DSA shows optimal positioning of the clip (white arrow). (H) Postoperative MRA illustrates complete patency of the A2 vessels. DSA, digital subtraction angiography; AcoA, anterior communicating artery; FU, follow up; MRA, magnetic resonance angiography

Fig. 7.

(A, B) DSA illustrates a ruptured supraophthalmic aneurysm of the right ICA (white arrow) that has been embolized with balloon-assisted technique. (C, D, E) Control angiogram shows a de novo aneurysm of the right carotid-T that has been completely embolized (red arrows). (F, G, H) Second FU angiogram shows aneurysm regrowth (red arrow) that has been definitely treated by surgical clipping (red arrow) whereas the supraophthalmic aneurysm remains stable (white arrow). (I, J) Post-surgical angiogram (DSA & 3D reconstruction) shows the optimal positioning of the clip (red and white arrows). DSA, digital subtraction angiography; ICA, internal carotid artery

Fig. 8.

(A) DSA (subtracted view) shows a ruptured wide-neck ACoA aneurysm (black arrow). (B) During embolization using balloonassisted technique penetration of the aneurysm occurred after deployment of the first coil (black arrow). (C) Further embolization with coils resulted in complete aneurysm occlusion (black arrow). (D) A FU angiography revealed a newly formed aneurysm projection (black arrow). (E) Intraoperative view shows the aneurysm bleb (black arrow). (F, G) A mini-clip has been used to occlude the new bleb (black arrow) followed by aneurysm wrapping. (H) Post-surgical angiogram shows complete occlusion of the aneurysm (black arrow). DSA, digital subtraction angiography; AcoA, anterior communicating artery

Fig. 9.

Recurrence types based on FU angiographies. Type I: coil loosening, Type II: coil compaction, Type III: aneurysm regrowth (IIIa: neck growth with or without coil compaction, IIIb: aneurysmal sac growth with or without coil compaction, IIIc: a new aneurysmal sac formed from the original aneurysmal neck), Type IV: coil migration (Type IVa: coil extrusion outside of the aneurysmal sac, Type IVb: coil protrusion in the parent artery)