gms | German Medical Science

Objective: Aneurysms of the posterior communicating artery (PCom) are among the most frequent and may have an increased risk for rupture. Since the International Subarachnoid Aneurysm Trial, coiling is often considered as the primary aneurysm treatment although aneurysm recurrence remains a significant drawback of this elegant method. We retrospectively reviewed patients with PCom-aneurysms treated at our center by either coiling or clipping and assessed long-term occlusion rates.

Method: All patients with aneurysms were entered into a prospectively collected database. For this study, patients treated between 2007 and 2013 harboring both ruptured and unruptured PCom-aneurysms were retrospectively selected. Long-term occlusion was statistically assessed.

Results: We included 127 patients into our study. Coiling was chosen in 100 patients and clipping in 27. Patients were assigned to the treatment on the basis of an interdisciplinary neurovascular team considering patient and aneurysm characteristics. The aneurysm had ruptured in 84 patients (84%) in the endovascular and 11 (40.7%) of the surgical group (p<0.001). Poor WFNS-grade patients were more often treated endovascularly (p=0.013). In the surgical group, patients had significantly more frequent multiple aneurysms (70.4 vs. 33%, p=0.001) and aneurysms more often had additional blebs of the aneurysm dome (59.3 vs. 27.3%, p=0.006). There was no significant difference in the age of the patients or aneurysm size in both groups (57.9 vs. 52.4 years and 7.2 vs. 8.9 mm in the endovascular vs. surgical groups, respectively). The aneurysm neck was classified as wide in 40.7% in clipped patients (endovascular: 26%, p>0.05). A cranial nerve palsy was noted in 18.5% of patients selected for clipping vs. 14% coiling (p>0.05). A second procedure due to aneurysm recurrence was necessary in 10% of endovascularly treated patients while at least some aneurysm reperfusion was noted in 18%. Patients with aneurysms >7mm (p=0.004) or wide neck aneurysms (p=0.010) underwent repeated intervention more often. No clipped patient required repeated treatment. The projection of the aneurysm dome was not associated with the need for reintervention. In a multivariate analysis, aneurysm size >7mm was the only predictor for reintervention.

Conclusions: In general, endovascular occlusion of PCom aneurysms is safe. But in aneurysms >7mm in size, surgical treatment might be preferable due to an increased risk of aneurysm reccurrence requiring reintervention.