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Experience with coil embolization of previously clipped aneurysms presenting with rupture
  1. Alejandro M Spiotta1,2,
  2. Albert Schuette3,
  3. Ferdinand Hui2,
  4. Rishi Gupta4,
  5. Charles M Cawley3,
  6. Shaye I Moskowitz1,2
  1. 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
  3. 3Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
  4. 4Vanderbilt University Medical Center, Nashville, Tennessee, USA
  1. Correspondence to Shaye I Moskowitz, Cerebrovascular Center, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, S80, Cleveland, OH 44195, USA; moskows{at}ccf.org

Abstract

Introduction Endovascular coil embolization has an established role alongside microsurgical clipping in the treatment of aneurysms. We studied previously clipped aneurysms that presented as subarachnoid hemorrhage and were treated by coil embolization.

Methods A retrospective review was performed of two prospectively maintained databases from two institutions (Cleveland Clinic, Emory University) that spanned 12 years.

Results Seven patients were identified (mean age 56.9 years) who had previously undergone surgical clipping for aneurysm obliteration; six (86%) were previously ruptured. Patients presented with aneurysm rupture with a mean time of 11.5 years (range 4 months to 20 years) following surgical treatment. Aneurysm location included anterior communicating artery (n=4), posterior communicating artery (n=1), internal carotid artery terminus (n=1) and anterior choroidal (n=1). Three patients presented in Hunt and Hess (HH) grade 1, one in HH2, two in HH3 and one in HH4. Four of the patients underwent unassisted coil embolization while balloon assistance was employed in three. Angiographic results were as follows: complete occlusion (n=3; 42.9%) and residual neck (n=4; 57.1%). There were no intraprocedural complications.

Conclusion Aneurysm rupture following surgical obliteration is a rare event and may occur remote from the initial treatment. Endovascular embolization with or without balloon assistance can be safely employed in cases of aneurysm recurrence rupture following surgical treatment with satisfactory angiographic treatment.

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Introduction

Endovascular coil embolization has an established role alongside microsurgical clipping in the treatment of intracranial aneurysms.1 Factors to be considered when choosing between the two treatment options include the risks and durability of each modality, operator preference and experience, in addition to availability of retreatment options should the need arise. Recent results from the CARAT study2 support the durability of microsurgical clipping over coil embolization, with most ruptures occurring in the immediate post-treatment period (median 3 days). The most significant predictive factor for the rare post-treatment aneurysmal ruptures was degree of occlusion. In the contemporary era of aneurysm treatment, both modalities in combination may frequently be employed to achieve satisfactory occlusion. As coil embolization has become more widespread beginning in the mid- to late 1990s and this modality is associated with the highest risk of aneurysm recurrence, the majority of the literature focuses on retreatment of aneurysms that were previously coiled with surgery and the unique challenges that this new paradigm presents.3–15 Repeat coil embolization has also been employed successfully to treat recurrent aneurysms that were initially coiled.14 15

Experience with coil embolization of aneurysms that were initially treated by microsurgical clipping is sparse, with the majority of reports describing cases in which coiling was employed as part of a planned, staged approach or in the elective treatment of routinely detected postoperative recurrences.16–18 For treatment of aneurysmal recurrences, scarring of the arachnoid can render microsurgical dissection more difficult, especially in the setting of previously ruptured aneurysms. For this reason, unless absolutely contraindicated, we favor treating these rare re-ruptures with coil embolization, although we have not systematically studied the success rate of this strategy. We studied previously clipped aneurysms that presented as subarachnoid hemorrhage and were treated by coil embolization.

Methods

A retrospective review was performed of two prospectively maintained databases of aneurysm treatments from two institutions (Cleveland Clinic and Emory University) that spanned 12 years. Subarachnoid hemorrhage patients who had previously undergone microsurgical clipping of the index aneurysm were identified. We reviewed the demographic, angiographic, radiographic and outcome data for each of these patients. Angiographic occlusion was determined using the Raymond classification (1, complete occlusion; 2, remnant neck; 3, remnant aneurysm; 4, treatment failure).19 We report our experience with these patients.

Results

Seven patients were identified (five female and two male, mean age 56.9±9 years) who had previously undergone surgical clipping for aneurysm obliteration and who presented with subarachnoid hemorrhage from the index aneurysm. Six of these (86%) were previously ruptured. Table 1 summarizes the patient data. Patients presented with aneurysm rupture with a mean time of 11.5±8 years (range 4 months to 20 years) following surgical treatment. Aneurysm location included the anterior communicating artery (n=4), posterior communicating artery (n=1), internal carotid artery terminus (n=1) and anterior choroidal artery (n=1). Three patients presented in Hunt and Hess (HH) grade 1, one in HH2, two in HH3 and one in HH4; two in Fisher (F) 1, one in F3 and four in F4.

Table 1

Summary of demographics, prior aneurysm treatment, clinical grade and size of aneurysm recurrence, treatment strategy including technical details, radiographic results and clinical outcomes for all patients

All procedures were technically successful. Four of the patients underwent unassisted coil embolization while balloon assistance was employed in three. The balloons employed included the Hyperform (Ev3 Endovascular, Inc., Plymouth, Minnesota, USA) and Hyperglide (Ev3 Endovascular, Inc.). Two straight microcatheters were employed to catheterize the aneurysm: Excelsior SL-10 (Boston Scientific, Natick Massachusetts, USA) and Headway (Microvention, Tustin California, USA). Heparin anticoagulation was administered in all but one case by operator preference and a wide variety of coils were used as outlined in table 1.

Angiographic results were as follows: complete occlusion (n=3; 42.9%) and residual neck (n=4; 57.1%) (figure 1). There were no intraprocedural complications. Outcomes included modified Rankin Scale (mRS) 0 (n=2), 1 (n=2), 2 (n=1), 5 (n=1) and one death. Outcome was associated with clinical grade on presentation: for HH1 (mRS 0, 0, 1), HH2 (mRS 1), HH3 (mRS 2, 5), HH4 (mRS 6).

Figure 1

Representative images from three of the patients. (A–E) Patient 3, admission CT scan, anteroposterior (AP) and lateral (lat) subtracted angiogram demonstrates recurrence of a previously clipped anterior communicating artery aneurysm. Post-treatment AP and lat angiograms demonstrate coiling of the aneurysm to complete occlusion. (F–J) Patient 2, CT, AP and lat pretreatment and post-treatment angiograms demonstrate the bilobed anterior communicating artery recurrent aneurysm that was treated to near complete occlusion with a small residual neck. (K–N) Patient 1, CT, oblique AP and lat pretreatment and oblique AP angiograms post-treatment of a recurrent ICA terminal aneurysm with a small residual neck.

Discussion

Aneurysm rupture following microsurgical obliteration is an exceedingly rare event. We report our experience treating remotely clipped aneurysms that presented as subarachnoid hemorrhage by endovascular coil embolization. While much attention has been drawn to the challenges inherent in surgical treatment of recurrent or inadequately coiled aneurysms,3–13 much less is known about coiling previously clipped aneurysms that have ruptured. This largely reflects the rarity of the event. In a period spanning 12 years in two high-volume tertiary care centers, seven cases were identified. Earlier reports of coil embolization of incompletely clipped or recurrent aneurysms focused on elective cases16–18 and due to rapid technological advances in the field may not necessarily reflect treatment in the contemporary era.

We have found that endovascular embolization with or without balloon assistance can be safely employed in cases of aneurysm recurrence rupture following surgical treatment with satisfactory angiographic treatment. There were no treatment failures or technical complications and outcome is associated mainly with clinical grade on presentation without apparent added morbidity due to treatment. Although this study was not designed or powered to address which treatment modality is the safest and most effective in this setting, we believe that microsurgical dissection would be challenging due to scarring and our preliminary results confirm the efficacy of coiling as a rescue strategy for these difficult cases. Further long-term studies are needed to assess the durability and protection from future rupture episodes employing this approach.

Key messages

  • Aneurysms can be treated with surgery or coil embolization.

  • Very rarely, aneurysms that were treated successfully with surgery may recur and rupture.

  • We studied coil embolization as a treatment strategy in these rare cases of recurrence with hemorrhage following surgical treatment.

  • Coil embolization can be done safely and effectively for the treatment of these aneurysms, and is likely preferable to surgery in this setting.

References

View Abstract

Footnotes

  • Competing interests None.

  • Ethics approval Ethics Committee Approval The database is prospectively collected and approved by the Institutional Review Board of the Cleveland Clinic, Cleveland, Ohio.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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