Neurosurgical Management of Previously Coiled Recurrent Intracranial Aneurysms

Abstract

Objective: Endovascular treatment of cerebral aneurysms with detachable coils has proven to be a save and effective treatment. But long-term recurrence due to aneurysm regrowth or coil compaction has been reported in up to thirty percent of cases. Therefore a growing number of previously coiled aneurysms have to be retreated by coiling or, in some circumstances, by clipping. We present a consecutive series of ten patients who underwent surgical clipping for recurrent aneurysms after primary coil embolization.

Methods: During a 4-year period ten patients with intracranial aneurysms previously treated by coil embolization underwent surgery for clipping of recanalized aneurysms. All aneurysms were located in the anterior circulation (internal carotid artery [ICA], 2; middle cerebral artery [MCA], 3; anterior communicating artery [AcomA], 5). Clinical data and imaging studies of the patients were analyzed retrospectively.

Results: All recurrences were detected by routine control angiograms within a median period of 14 months after primary treatment. In three aneurysms treated for SAH dense arachnoid scarring around the aneurysm sac was noted. In four cases, coils were found intraoperatively to be extruding through the aneurysm sac into the subarachnoid space. Each aneurysm could be clipped without affecting the perfusion of the parent vessel. In one patient the aneurysm sac including the coil package was resected. In one patient one of the central anteromedial arteries was injured during dissection due to dense arachnoid scarring because of prior SAH. As a consequence infarction of the head of the caudate nucleus without neurological compromise was observed on follow-up CT scans. Another patient developed transient aphasia due to vasospasm in the early postoperative period with complete restitution. In the end all patients had an uneventful recovery. Removal of the coil package was not necessary in most cases. Clipping of the aneurysm neck was possible even in cases with coil dislocation into the parent vessel.

Conclusion: Clipping of previously coiled aneurysms is a unique problem for vascular neurosurgeons. In most cases clipping is feasible. Clipping should still be considered as a definite treatment option in previously coiled recurrent aneurysms. Results in this small series were good.

Zusammenfassung

Ziel: Die endovaskuläre Coilembolisation intrakranieller Aneurysmen gilt inzwischen als sicher und effektiv. Angiographische Langzeitstudien haben allerdings eine Rekanalisierungsrate gecoilter Aneurysmen von bis zu 30% beschrieben. Deshalb müssen rekanalisierte endovaskulär behandelte Aneurysmen zunehmend entweder durch erneute Coilembolisation, oder in bestimmten Fällen durch mikrochirurgisches Clipping behandelt werden. Wir präsentieren eine Serie von zehn Patienten, bei denen auf Grund einer Aneurysmarekanalisation nach primärer Coilembolisation ein Aneurysma-Clipping durchgeführt wurde.

Methode: Die retrospektive Studie über einen Zeitraum von 4 Jahren umfasst zehn Patienten, die nach primärer Coilembolisation auf Grund einer Aneurysmareperfusion offen mikrochirurgisch geclippt wurden. Es handelte sich ausschließlich um Aneurysmen des vorderen Kreislaufs.

Resultate: Alle Aneurysmareperfusionen wurden anlässlich von routinemäßigen Kontrollangiographien (Median 14 Monate) entdeckt. Bei 3 Aneurysmen, welche initial durch eine Ruptur mit konsekutiver SAB symptomatisch wurden, war die Aneurysmapräparation durch ausgedehnte arachnoidale Vernarbungen erschwert. Intraoperativ konnte in vier Fällen Coilmaterial außerhalb des eigentlichen Aneurysmasacks im Subarachnoidalraum gefunden werden. Jedes Aneurysma konnte durch einen Clip versorgt werden, ohne Beeinträchtigung der Perfusion des aneurysmatragenden Gefäßes. Bei einem Patienten wurde das Aneurysma inklusive Coil-Paket reseziert. Bei einem Patienten mit ausgedehnter arachnoidaler Vernarbung kam es bei der Präparation zu einer Verletzung einer der Aa. centrales anteromediales mit konsekutivem, klinisch folgenlosem Infarkt des Nucleus caudatus. Ein anderer entwickelte in der frühen postoperativen Phase einen symptomatischen Vasospasmus mit transienter Sprachproduktionsstörung, welche sich rasch und ohne Residuum zurückbildete. Schließlich boten alle Patienten ein zufriedenstellendes klinisches Endergebnis. Die Entfernung von Coilmaterial aus dem Aneurysma war in den meisten Fällen nicht erforderlich. Sogar im Fall einer Coildislokation in das aneurysmatragende Gefäß war ein Verschluss des Aneurysmahalses durch einen geeigneten Clip möglich.

Schlussfolgerung: Die offene chirurgische Behandlung zuvor embolisierter intrakranieller Aneurysmen stellt ein einzigartiges Problem für vaskulär tätige Neurochirurgen dar. In den meisten Fällen ist eine Ausschaltung des Aneurysmas durch ein Clipping möglich. Das mikrochirurgische Clipping zuvor embolisierter intrakranieller Aneurysmen sollte neben wiederholten endovaskulären Maßnahmen als Therapieoption dieser meist komplexen Läsionen mit in Betracht gezogen werden.

Key words

intracranial aneurysm - coiling - recanalization - clipping

Schlüsselwörter

intrakranielle Aneurysmen - Coiling - Rekanalisierung - Clipping

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