gms | German Medical Science

Objective: To report our experience concerning indications, technical challenges and clinical outcome in patients undergoing aneurysmal surgery following endovascular treatment.

Methods: We analyzed a series of 19 patients that underwent microsurgical treatment following endovascular treatment of either innocent or ruptured intracranial aneurysms during a 7-year period in our department. Clinical, radiological and intraoperative findings were retrospectively evaluated.

Results: In 19 patients (19–69 y, Mean: 42.2±14 y) previously coiled aneurysms were treated surgically. In 6 patients the primary aneurysms were innocent. In these patients surgical treatment was performed due to reperfusion/re-growth (3–9 mm, Mean: 5.2±2.7 mm) of the aneurysm observed in angiographical follow-up. 3 patients were treated within 12 months after initial endovascular treatment, 3 patients were treated within 7 years. Compaction of the coils was observed in all cases, extrusion of the coil material was observed in 3 cases. In all of these recurrent aneurysms clipping procedure was retrospectively classified as uncomplicated. All patients showed excellent clinical outcome (mRanking scale 0–1, Mean 0.2±0.2). Thirteen patients presented with initial subarachnoid hemorrhage (Hunt&Hess 1–4, Mean 1.9±1.1). In these patients surgical treatment was performed due to early (n=2) or delayed (n=1) rebleeding or reperfusion/re-growth (2–8 mm, Mean 4.1±2.1) in follow-up (n=10). Extrusion of the coil material was observed in 6 cases. 5 clipping procedures were retrospectively classified as complex, with necessity of temporary clipping, incision of the aneurysm dome and coil extraction. In the 3 patients suffering from rebleeding, 2 had a fatal outcome. All other patients showed an excellent clinical outcome (mRanking scale 0–1, Mean 0.3±0.5). In all patients (n=19) postoperative angiography showed complete obliteration of the aneurysm. Interestingly, 13 of the 19 patients angiographies showed significant generalized or local vessel elongations.

Conclusions: Clipping of previously coiled aneurysms can be performed safely in experienced hands. Previous subarachnoid hemorrhage seems to hamper surgical management. However, demanding procedures like aneurysm dome incision and coil extraction were only necessary in the minority of cases. Initial vessel elongation as observed by angiography showed high incidence and might be a predictive factor for compaction or re-growth of coiled aneurysms.