Clipping of previously coiled cerebral aneurysms: efficacy, safety, and predictors in a cohort of 111 patients

Abstract

OBJECTIVE With the increasing number of aneurysms treated with endovascular coiling, more recurrences are being encountered. The aim of this study was to evaluate the efficacy and safety of microsurgical clipping in the treatment of recurrent, previously coiled cerebral aneurysms and to identify risk factors that can affect the outcomes of this procedure. METHODS One hundred eleven patients with recurrent aneurysms whose lesions were managed by surgical clipping between January 2002 and October 2014 were identified. The rates of aneurysm occlusion, retreatment, complications, and good clinical outcome were retrospectively determined. Univariate and multivariate logistic regressions were performed to identify factors associated with these outcomes. RESULTS The mean patient age was 50.5 years, the mean aneurysm size was 7 mm, and 97.3% of aneurysms were located in the anterior circulation. The mean follow-up was 22 months. Complete aneurysm occlusion, as assessed by intraoperative angiography, was achieved in 97.3% of aneurysms (108 of 111 patients). Among patients, 1.8% (2 of 111 patients) had a recurrence after clipping. Retreatment was required in 4.5% of patients (5 of 111) after clipping. Major complications were observed in 8% of patients and mortality in 2.7%. Ninety percent of patients had a good clinical outcome. Aneurysm size (OR 1.4, 95% CI 1.08–1.7; p = 0.009) and location in the posterior circulation were significantly associated with higher complications. All 3 patients who had coil extraction experienced a postoperative stroke. Aneurysm size (OR 1.2, 95% CI 1.02–1.45; p = 0.025) and higher number of interventions prior to clipping (OR 5.3, 95% CI 1.3–21.4; p = 0.019) were significant predictors of poor outcome. An aneurysm size > 7 mm was a significant predictor of incomplete obliteration and retreatment (p = 0.018). CONCLUSIONS Surgical clipping is safe and effective in treating recurrent, previously coiled cerebral aneurysms. Aneurysm size, location, and number of previous coiling procedures are important factors to consider in the management of these aneurysms.

Perioperative Ischemic Stroke in Unruptured Intracranial Aneurysm Surgical or Endovascular Therapy

“…Previous research indicated that combined surgical and endovascular treatments may be safe and effective [18]. In a cohort study involving 111 patients who underwent clipping of previously coiled IA, 2.7% had major complications and underwent coil extraction as a result of post-operative stroke [26]. By contrast, we found that ischemic stroke was less frequent in the context of SAC or BAC as compared to surgical clipping alone among patients with unruptured IA.…”

Clipping as re-treatment strategy after treatment of a cerebral aneurysm with the Woven EndoBridge embolization device: case report

“…Additionally, 90% of patients had a good clinical outcome with modified Rankin Scale scores of 0-2. 4,15 Surgical clipping is a permanent solution in almost all cases, and, if aneurysm occlusion is verified by DSA, further recurrence is very rare. 14 Wallner et al reported a positive experience with the case of regrowth of a middle cerebral artery aneurysm that was initially occluded with a WEB device, recurred, and was re-treated with coiling.…”

“…8 Similarly, in their cohort of 111 patients, Daou et al reported complete occlusion rates of 97.3% after re-treatment by clipping, indicating the safety and effectiveness of clipping as the re-treatment method after previous coiling. 4 Even if the procedure is safe and leads to high occlusion rates without increased complications, some aspects need to be considered before surgery. Coil extraction might be necessary in some cases to achieve complete aneurysm occlusion or better anatomical preparation due to profound scarring.…”

“…However, coil extraction seems to be associated with a higher risk for stroke, which might result in a severe neurological deficit. 4 The risk of WEB extrusion seems to be less likely due to the nature of this device. Additionally, we found no scarring while preparing the aneurysm for clipping due to the soft nature of the WEB.…”

Surgical Clipping of Previously Ruptured, Coiled Aneurysms: Outcome Assessment in 53 Patients

“…In previous reports, the majority of patients who underwent microsurgical clipping of a previously coiled aneurysm had "no change" or an "improved" outcome. 6,10,18,19,22,24,25,[39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56] Currently, the largest prospective series of subjects who underwent clipping of previously coiled aneurysms is the International Subarchnoid Aneurysm Trial (n=191), but it does not provide outcomes for this particular subset-group. 6 Although, this may be beneficial by having reduced surgeon expertise bias, it simultaneously 281 introduces risk for other confounding factors such as selection bias.…”