gms | German Medical Science

Objective: For an increasing number of patients, endovascular obliteration of an intracranial aneurysm is the first treatment option. New devices facilitate endovascular therapy of aneurysms with wider neck or extended dysplastic vessel wall which may be involved in the aneurysm base. However, in few cases long term obliteration of the aneurysm is not achieved and retreatment is necessary. Although endovascular retreatment is often possible, in some cases surgical treatment is necessary for safe and permanent aneurysm obliteration.

Method: From December 2008 to October 2012, 10 consecutive patients with previous endovascular treatment were analyzed. All aneurysms were located in the anterior circulation (anterior communicating artery in 5 patients). Details from operative reports and patient charts were obtained and outcome was assessed during the last visit at our institution.

Results: 10 patients underwent surgical therapy after initial endovascular treatment. Indications for surgery were recurrence due to coil compaction (n=5), periprocedural rupture (n=3), incomplete coiling (n=1) and de novo aneurysm in secondary location (n=1). Aneurysms had been incidental in 2, symptomatic in 1 and presented with SAH in 7 cases. Surgical treatment was performed 0-69 months after initial therapy (mean 18 months), immediately after coiling in 3 cases. Coil protrusion into the parent vessel was found in 2 cases. Direct clipping was possible in 9/10 cases, one aneurysm was wrapped only. The number of clips varied from 1-4. In 4 cases, coils caused slipping of clips during application. Temporary clipping was necessary in 5/10 cases. In one patient, the aneurysm was perforated by the guide wire which was removed by the interventionalist in the operating room and the clip was instantly applied. Removal of coils was performed in 3/10 cases. Rupture of the aneurysm or small perforating arteries occurred in 2 cases each. Postoperative angiography showed complete occlusion in 8 patients and minimal residual aneurysm in 2 patients. Outcome was favourable in 8/10 patients (GOS 4 and 5).

Conclusions: Microsurgical clipping of endovascular pretreated intracranial aneurysms is challenging especially after stent assisted coiling. Careful risk assessment and close interdisciplinary collaboration are prerequisites for successful treatment and good clinical outcome.