Combined Management of Intracranial Aneurysms by Surgical and Endovascular Treatment. Modalities and Results from a Series of 395 Cases

Abstract

The selective occlusion of saccular intracranial aneurysms may be achieved by two techniques: microsurgical clipping and endovascular coiling. Each of them have particular indications which need to be defined. We report on a series in which both techniques were applied. From September 1992 to June 1996, 395 consecutive patients with small or large aneurysm were treated either by surgery (N = 102) or by endovascular coiling (N = 293). Coiling was chosen each time the shape of the aneurysm seemed to be appropriate for this treatment: narrow neck and ratio neck diameter by sac diameter less than one third. Satisfactory results with complete or subtotal obliteration and no recanalization on the following controls at 1, 6, 12 and 36 months, were obtained in 92% before retreatment and in 98.8% after retreatment. Unsatisfactory results were observed after surgery in 7 cases and in 25 cases after embolization. After retreatment, it remains 3 post-surgical and 2 post-endovascular cases. In the overall series, good and excellent clinical outcome was noted in 90% for small aneurysms and in 86.5% for large ones; mortality was of 4.8%. In a series in which were applied both types of treatment, surgery in 25% and endovascular technique in 75%, good results in terms of aneurysm occlusion and clinical results were achieved. These results are as good as the best series in which surgery was the only choice. Therefore with appropriate selection, endovascular treatment is a good alternative for treatment of the majority of saccular aneurysms.

Single-Center Experience of Surgical and Endovascular Treatment of Ruptured Intracranial Aneurysms

“…Coiling is known to result in lower rates of complete occlusion compared with microsurgical clipping, which may affect the long-term stability and rates of rebleeding. [8][9][10][11] In the present study, a residual aneurysm was seen at postprocedural imaging in 14.2% of the patients having undergone endovascular treatment and in 4.3% of those treated by surgery. This group of neurosurgically treated aneurysms probably forms a selected population because posttreatment imaging was not standard procedure in the first years of inclusion.…”

“…7 Moreover, coiling achieves lower rates of complete occlusion compared with microsurgical clipping, which may affect the long-term stability and rates of rebleeding. [8][9][10][11] The results of ISAT were based on a selected patient population suitable for both endovascular and surgical treatment in a trial setting. Little data are available on the outcome of patients who are either endovascularly or surgically treated in a routine clinical practice.…”

Computerized Angiographic Occlusion Rating for Ruptured Clipped Aneurysms is Superior to Subjective Occlusion Rating

“…Comparing the high number of "misclippings" (21% with SOR) with literature data, one can find that of 5 publications dealing with angiographic clipping rates, 5 describe patients having both ruptured and unruptured aneurysms; there, the rates of misclipping are 4.4%-18.6%. [15][16][17][18] The only report analyzing only patients clipped after subarachnoid hemorrhage as in the current study is the one by Yu et al, 19 who, in 2007, described a series of 169 patients with ruptured aneurysms. The authors disclosed a misclipping rate of 16%, but there was no comparable information about preoperative clinical grading in this study, because "patients in poor conditions warranted greater delay."…”

Estudo comparativo entre aneurismas rotos tratados por cirurgia e por via endovascular

“…Lot et al 9 relatam 29% de tratamentos incompletos em sua série de 293 aneurismas embolizados. Raftopoulos et al 11 relatam 31,2% de oclusão sub-total ou incompleta em sua série de 64 aneurismas embolizados.…”

“…A recanalização dos aneurismas, após o tratamento por GDC e que necessitam de tratamento complementar, não é rara, com porcentagens variáveis [4][5][6][7][8][9][10][11][12][13]15,[18][19][20][21][22] . Em nossa série de aneurismas rotos, tratados por GDC, encontramos 33,3% de tratamento incompleto.…”