Definitive Treatment With Microsurgical Clipping After Recurrence and Rerupture of Coiled Anterior Cerebral Artery Aneurysms

Abstract

BACKGROUND The extent of obliteration of ruptured intracranial aneurysms treated with coil embolization has been correlated with the risk of rerupture. However, many practitioners consider that a small neck remnant is unlikely to result in significant risk after coiling. OBJECTIVE To report our recent experience with ruptured anterior cerebral artery aneurysms treated with endovascular coiling, which recurred or reruptured, requiring microsurgical clipping for subsequent treatment. METHODS Retrospective review of patients with intracranial aneurysms treated at our institution since August 2018. Patient and aneurysm characteristics, initial and subsequent treatment approaches, and outcomes were reviewed. RESULTS Six patients were included. Out of those 6 patients, 5 patients had anterior communicating artery aneurysms, and 1 patient had a pericallosal aneurysm. All initially presented with subarachnoid hemorrhage (SAH) and were treated with coiling. Recurrence occurred at a median of 7.5 mo. In 2 cases, retreatment was initially performed with repeat endovascular coiling, but further recurrence was observed. Rerupture from the residual or recurrent aneurysm occurred in 3 cases. In 2 cases, the aneurysm dome recurred; in 1 case, rerupture occurred from the neck. All 6 patients underwent treatment with microsurgical clipping. Follow-up catheter angiography demonstrated a complete occlusion of the aneurysm in all cases with the preservation of the parent vessel. CONCLUSION Anterior cerebral artery aneurysms may recur after endovascular treatment, and even small neck remnants present a risk of rerupture after an initial SAH. Complete treatment requires a complete exclusion of the aneurysm from the circulation. Even in cases that have been previously coiled, microsurgical clipping can represent a safe and effective treatment option.

Surgical Clipping of Previously Coiled Recurrent Intracranial Aneurysms: A Single-Center Experience

“…Aneurysm recurrence after endovascular coiling is a common problem, occurring in around of 30% cases depending on the series ( 12 , 13 ). Many studies reported that the size and neck width of IAs, aneurysm rupture, initially incomplete occlusion, packing densities, the use of stent, and length of follow-up contributed to an increased risk of IA recurrence ( 4 , 5 ). The mechanisms of aneurysm recurrence after EVT were summarized as follows ( Figure 1 ): coil compaction ( Figure 2 ), aneurysm regrowth ( Figure 3 ), and fundal migration ( Figure 4 ).…”

“…Although short-term safety of endovascular treatment is well-established, the long-term recurrence rate of IAs treated by coiling can be as high as 15-34% (1)(2)(3). In contrast, the recurrence rate among clipped patients was about 1-3% (4)(5)(6). Many reasons contributing to coiled aneurysm recurrence include initial incomplete aneurysm occlusion, regrowth, and coil compaction and migration, which required retreatment to prevent IA rupture or mass effect.…”

Surgery for multiple cerebral aneurysms: Literature review and case report

“…По данным различных авторов, неполное выключение аневризмы при эндоваскулярном лечении может составлять от 8,3 до 70,4 % (1-2-й классы по классификации Raymond-Roy), данные могут значительно отличаться в зависимости от способа оценки радикальности выключения [35][36][37][38]. Частота реканализации одиночных ЦА после эндоваскулярной окклюзии достигает 20 % при катамнезе наблюдения за 10 лет [39], поэтому повторные кровоизлияния после эмболизации ЦА возникают в 2-3 раза чаще, чем после клипирования (3,4 против 1,3 %) [37,[40][41][42]. Прочие осложнения эндоваскулярного выключения ЦА: миграция и выпадение микроспиралей в несущие сосуды (0,6-2,7 % случаев), интраоперационый разрыв (0,8-6,9 % случаев), которые сопровождаются крайне неблагоприятными исходами лечения [8,19,25,35,37,39].…”