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The Surgical Management of Previously Coiled Cerebral Aneurysms
Perspectives Commentary on: Microsurgical Clipping of Previously Coiled Aneurysms by Rubino et al. World Neurosurg 82:E203-E208, 2014
The Surgical Management of Previously Coiled Cerebral Aneurysms Joseph C. Serrone and Juha Hernesniemi
G
uglielmi et al. (10) reported the first use of detachable coils for treating cerebral aneurysms in 15 patients in 1991. This same pioneering group reported the open microsurgical management after partial coil embolization in 8 of their first 141 cases (5.7%). Surgical treatment included clipping (5 cases), trapping with bypass (2 cases), and parent vessel sacrifice (1 case). These surgeries resulted in complete aneurysm occlusion in 7 of 8 cases. In 3 of these cases, the aneurysm dome was opened intraoperatively several months after coiling. The authors report the coil mass could not be removed because of the formation of a dense fibrotic mass. Although these authors had good or excellent outcomes in all cases, cerebrovascular surgeons obtained their first glimpse of future challenges (3).
As we have seen from several series, the ability of coils to completely occlude aneurysms and the long-term durability of coiling in cerebral aneurysms are the major drawback of this therapy (1, 4, 5, 8). Recently, Pyysalo et al. (8) reported long-term results (mean follow-up ¼ 11 years) of coiling cerebral aneurysms. These investigators found incomplete coiling in ruptured and unruptured aneurysms of 15% and 37%, respectively. Additionally, 32% of ruptured aneurysms and 22% of unruptured aneurysms had neck remnants. Repeat treatment with endovascular therapy is unsuccessful, even with the use of modern intracranial stents. In their report of treating aneurysm recurrences in 350 of 2759 aneurysms (12.7%), Henkes et al. (4) were only able to obtain complete occlusion after a second treatment in 46.9% and after a third treatment in 35.2%. This inability of endovascular therapy to completely occlude aneurysms, even with follow-up and aggressive retreatment, requires cerebrovascular surgeons to know how to manage these cases. As more patients are receiving coiling for treatment of cerebral aneurysms, many cerebrovascular surgeons are reporting their
Key words Aneurysm - Clipping - Embolization - Previously coiled - Subarachnoid hemorrhage -
WORLD NEUROSURGERY 83 [4]: 481-482, APRIL 2015
experience in dealing with these increasingly prevalent and challenging cases (12). Currently, there are nearly 300 cases reported in the literature and the treatment results of another 103 cases in the International Subarachnoid Aneurysm Trial (ISAT) (2). In the ISAT and Barrow Ruptured Aneurysm Trial (BRAT), coiling had remnants requiring retreatment at 1 year in 17.4% and 10.6% of cases, respectively. This compares unfavorably with retreatment among clipped aneurysms occurring in 3.8% and 4.4% of cases, respectively (5, 11). When retreatment was performed on coiled aneurysms in ISAT, this was done by open surgery in 54% of cases. This equates to 9.4% of all coiled ruptured aneurysms in ISAT requiring retreatment by open surgery (2). The Finnish experience from neurosurgical centers in Helsinki and Kuopio reported the surgical treatment of 82 coiled aneurysms in 81 patients. This currently represents the largest series in the literature. Twenty-two percent of aneurysms were large or giant, 71% were anterior circulation (anterior communicating artery being the most common location), and 18% were performed acutely after subarachnoid hemorrhage. Much like the early experience of this operation reported by Gurian et al. (3), we found that complete coil removal was difficult in the later presentations because of fibrosis of the coil mass within the aneurysm sac (13% of late presenting aneurysms had coils removed vs. 80% of early presenting aneurysms). It was also nearly impossible and dangerous to the patient to remove coils from the posterior circulation. Temporary clipping was required in 52% of cases, but this only averaged 5 minutes and did not negatively affect outcome. The ability to achieve complete aneurysm occlusion was 94%, with 88% of patients neurologically stable or improved at 3 months. The only predictor of poor outcome in multivariate analysis was posterior circulation aneurysms. In 8 of 77 patients receiving postoperative vascular imaging, inadvertent closure of the parent vessel was identified (9).
Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland To whom correspondence should be addressed: Juha Hernesniemi, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 4:481-482. http://dx.doi.org/10.1016/j.wneu.2014.08.055
www.WORLDNEUROSURGERY.org
481
PERSPECTIVES
Ultimately, the goal of treatment in cases of incomplete coiling and growing remnants is occlusion of the aneurysm from the parent vessel. For this to be done by surgical means, a soft aneurysm neck must be present. If the coils are compacted into the dome leaving a capacious neck, then the aneurysm can often be simply clipped without coil removal. If coils are present near the neck, they can be easily removed in the early period (less than 1 month after placement) and this was done in 80% of our cases that presented early (9). Opening the aneurysm for coil removal obviously requires flow arrest with temporary clipping and/or adenosine.
but they will be irreversibly damaged after cutting platinum coils. Every effort should be made to form a soft neck to the aneurysm for clipping. The 8 cases (10.3%) that revealed postoperative parent artery closure in our series were likely a result of slipping of the clip from a solid aneurysm neck to the parent vessel. If reconstruction of the neck is not possible by coil removal, 3 options exist: 1) resection of the aneurysm with primary repair of the parent vessel using suture or Anastoclips (LeMaitre Vascular Inc., Burlington, Massachusetts, USA); 2) parent vessel trapping with or without bypass; or 3) aneurysm wrapping with muslin.
If coils have been in place much longer than 1 month, their removal is much more difficult. Also, removal of coils incorporated in the intima of the parent vessel or perforating vessels is not advised, as this will damage these vessels. Attempts at clipping aneurysms with a solid neck usually results in failure of the clip tips to close leaving persistent filling through the distal aneurysm neck. Sometimes, this can be addressed by placing a fenestrated clip over the first clip to close the distal aspect of the neck. Addressing the same problem, Nussbaum et al. has made a modification of a Sugita fenestrated clip (Mizuho America Inc., Union City, California, USA) so the blades are not opposed at closure. This design, termed a “compression clip,” may be useful for clipping previously coiled aneurysms (6). Often, however, these aneurysms need a more complex procedure. Preoperative angiographic assessment can help determine whether simple clipping will be feasible. In their analysis of 43 cases, Waldron et al. (12) found the ratio of the width of the coil mass to the height of the residual neck predicted the complexity of repair in 70%75% of cases.
Aside from the microsurgical management of coiled aneurysms is the prevention of certain cases. This applies mostly to large and giant aneurysms treated by endovascular means. The recurrence rate in this small subset of aneurysm patients may be as high as 50% (7). Surgical treatment of large and giant aneurysms after packing of coils within the dome is extremely challenging and often dangerous. It is true that early dome protection may be achieved with coiling at low morbidity and that early surgical morbidity is substantial with large aneurysms. However, strong consideration should still be given toward primary surgical treatment, because this may be the patient’s only chance for long-term aneurysm occlusion. This decision-making process is aided by centralization of aneurysm patients at centers with both open cerebrovascular and endovascular expertise.
When clipping cannot be performed primarily, preparation of the aneurysm neck may require cutting the coils after opening of the aneurysm sac. Cutting platinum coils can be done with Aesculap wire cutting microscissors (B. Braun, Melsungen, Germany) or the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, Colorado, USA). Standard microscissors can be used,
REFERENCES 1. Byrne JV, Sohn MJ, Molyneux AJ, Chir B: Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding. J Neurosurg 90:656-663, 1999. 2. Campi A, Ramzi N, Molyneux AJ, Summers PE, Kerr RS, Sneade M, Yarnold JA, Rischmiller J, Byrne JV: Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT). Stroke 38:1538-1544, 2007. 3. Gurian JH, Marin NA, King WA, Duckwiler GR, Guglielmi G, Vinuela F: Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization. J Neurosurg 83:843-853, 1995. 4. Henkes H, Fischer S, Liebig T, Weber W, Reinartz J, Miloslavski E, Kuhne D: Repeated endovascular coil occlusion in 350 of 2759 intracranial aneurysms: safety and effectiveness aspects. Neurosurgery 58:224-232; discussion 24-32, 2006. 5. Molyneux AK, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M, Rischmiller J, for the ISAT Collaborators: Risk of recurrent subarachnoid
482
www.SCIENCEDIRECT.com
Endovascular therapy for the treatment of cerebral aneurysms has increased in recent years (10). Although results in the surgical treatment of previously coiled aneurysms are favorable in most case series, the technical challenges faced in these cases are formidable. These surgical nuances must be discussed and taught, as these cases will only become more common in the future. And, finally, the care of aneurysm patients should be centralized. This will allow the risks associated with a complex surgical repair of a coiled aneurysm to be considered before determining the primary treatment of an aneurysm.
haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 8:427-433, 2009. 6. Nussbaum ES, Nussbaum LA: A novel aneurysm clip design for atheromatous, thrombotic, or previously coiled lesions: preliminary experience with the “compression clip” in 6 cases. Neurosurgery 67:333-341, 2010. 7. Piotin M, Blanc R, Spelle L, Mounayer C, Piantino R, Schmidt PJ, Moret J: Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke 41:110-115, 2010. 8. Pyysalo LM, Keski-Nisula LH, Niskakangas TT, Kahara VJ, Ohman JE: Long-term follow-up study of endovascularly treated intracranial aneurysms. Interv Neuroradiol 16:231-329, 2010.
10. Guglielmi G, Vineula F, Dion J, Duckwiler G: Electromthrombosis of saccular aneurysms via endovascular approach. J Neurosurg 75:8-14, 1991. 11. Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, Nakaji P, Wallace RC: The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg 119:146-157, 2013. 12. Waldron JS, Halbach VV, Lawton MT: Microsurgical management of incompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery 64: 301-315; discussion 15-17, 2009.
Citation: World Neurosurg. (2015) 83, 4:481-482. http://dx.doi.org/10.1016/j.wneu.2014.08.055 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
9. Romani R, Lehto H, Laakso A, Horcajadas A, Kivisaari R, von und zu Fraunberg M, Niemela M, Rinne J, Hernesniemi J: Microsurgery for previously coiled aneurysms: experience with 81 patients. Neurosurgery 68:140-153; discussion 53-54, 2011.
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.08.055
The Surgical Management of Previously Coiled Cerebral Aneurysms Joseph C. Serrone and Juha Hernesniemi
G
uglielmi et al. (10) reported the first use of detachable coils for treating cerebral aneurysms in 15 patients in 1991. This same pioneering group reported the open microsurgical management after partial coil embolization in 8 of their first 141 cases (5.7%). Surgical treatment included clipping (5 cases), trapping with bypass (2 cases), and parent vessel sacrifice (1 case). These surgeries resulted in complete aneurysm occlusion in 7 of 8 cases. In 3 of these cases, the aneurysm dome was opened intraoperatively several months after coiling. The authors report the coil mass could not be removed because of the formation of a dense fibrotic mass. Although these authors had good or excellent outcomes in all cases, cerebrovascular surgeons obtained their first glimpse of future challenges (3).
As we have seen from several series, the ability of coils to completely occlude aneurysms and the long-term durability of coiling in cerebral aneurysms are the major drawback of this therapy (1, 4, 5, 8). Recently, Pyysalo et al. (8) reported long-term results (mean follow-up ¼ 11 years) of coiling cerebral aneurysms. These investigators found incomplete coiling in ruptured and unruptured aneurysms of 15% and 37%, respectively. Additionally, 32% of ruptured aneurysms and 22% of unruptured aneurysms had neck remnants. Repeat treatment with endovascular therapy is unsuccessful, even with the use of modern intracranial stents. In their report of treating aneurysm recurrences in 350 of 2759 aneurysms (12.7%), Henkes et al. (4) were only able to obtain complete occlusion after a second treatment in 46.9% and after a third treatment in 35.2%. This inability of endovascular therapy to completely occlude aneurysms, even with follow-up and aggressive retreatment, requires cerebrovascular surgeons to know how to manage these cases. As more patients are receiving coiling for treatment of cerebral aneurysms, many cerebrovascular surgeons are reporting their
Key words Aneurysm - Clipping - Embolization - Previously coiled - Subarachnoid hemorrhage -
WORLD NEUROSURGERY 83 [4]: 481-482, APRIL 2015
experience in dealing with these increasingly prevalent and challenging cases (12). Currently, there are nearly 300 cases reported in the literature and the treatment results of another 103 cases in the International Subarachnoid Aneurysm Trial (ISAT) (2). In the ISAT and Barrow Ruptured Aneurysm Trial (BRAT), coiling had remnants requiring retreatment at 1 year in 17.4% and 10.6% of cases, respectively. This compares unfavorably with retreatment among clipped aneurysms occurring in 3.8% and 4.4% of cases, respectively (5, 11). When retreatment was performed on coiled aneurysms in ISAT, this was done by open surgery in 54% of cases. This equates to 9.4% of all coiled ruptured aneurysms in ISAT requiring retreatment by open surgery (2). The Finnish experience from neurosurgical centers in Helsinki and Kuopio reported the surgical treatment of 82 coiled aneurysms in 81 patients. This currently represents the largest series in the literature. Twenty-two percent of aneurysms were large or giant, 71% were anterior circulation (anterior communicating artery being the most common location), and 18% were performed acutely after subarachnoid hemorrhage. Much like the early experience of this operation reported by Gurian et al. (3), we found that complete coil removal was difficult in the later presentations because of fibrosis of the coil mass within the aneurysm sac (13% of late presenting aneurysms had coils removed vs. 80% of early presenting aneurysms). It was also nearly impossible and dangerous to the patient to remove coils from the posterior circulation. Temporary clipping was required in 52% of cases, but this only averaged 5 minutes and did not negatively affect outcome. The ability to achieve complete aneurysm occlusion was 94%, with 88% of patients neurologically stable or improved at 3 months. The only predictor of poor outcome in multivariate analysis was posterior circulation aneurysms. In 8 of 77 patients receiving postoperative vascular imaging, inadvertent closure of the parent vessel was identified (9).
Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland To whom correspondence should be addressed: Juha Hernesniemi, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 4:481-482. http://dx.doi.org/10.1016/j.wneu.2014.08.055
www.WORLDNEUROSURGERY.org
481
PERSPECTIVES
Ultimately, the goal of treatment in cases of incomplete coiling and growing remnants is occlusion of the aneurysm from the parent vessel. For this to be done by surgical means, a soft aneurysm neck must be present. If the coils are compacted into the dome leaving a capacious neck, then the aneurysm can often be simply clipped without coil removal. If coils are present near the neck, they can be easily removed in the early period (less than 1 month after placement) and this was done in 80% of our cases that presented early (9). Opening the aneurysm for coil removal obviously requires flow arrest with temporary clipping and/or adenosine.
but they will be irreversibly damaged after cutting platinum coils. Every effort should be made to form a soft neck to the aneurysm for clipping. The 8 cases (10.3%) that revealed postoperative parent artery closure in our series were likely a result of slipping of the clip from a solid aneurysm neck to the parent vessel. If reconstruction of the neck is not possible by coil removal, 3 options exist: 1) resection of the aneurysm with primary repair of the parent vessel using suture or Anastoclips (LeMaitre Vascular Inc., Burlington, Massachusetts, USA); 2) parent vessel trapping with or without bypass; or 3) aneurysm wrapping with muslin.
If coils have been in place much longer than 1 month, their removal is much more difficult. Also, removal of coils incorporated in the intima of the parent vessel or perforating vessels is not advised, as this will damage these vessels. Attempts at clipping aneurysms with a solid neck usually results in failure of the clip tips to close leaving persistent filling through the distal aneurysm neck. Sometimes, this can be addressed by placing a fenestrated clip over the first clip to close the distal aspect of the neck. Addressing the same problem, Nussbaum et al. has made a modification of a Sugita fenestrated clip (Mizuho America Inc., Union City, California, USA) so the blades are not opposed at closure. This design, termed a “compression clip,” may be useful for clipping previously coiled aneurysms (6). Often, however, these aneurysms need a more complex procedure. Preoperative angiographic assessment can help determine whether simple clipping will be feasible. In their analysis of 43 cases, Waldron et al. (12) found the ratio of the width of the coil mass to the height of the residual neck predicted the complexity of repair in 70%75% of cases.
Aside from the microsurgical management of coiled aneurysms is the prevention of certain cases. This applies mostly to large and giant aneurysms treated by endovascular means. The recurrence rate in this small subset of aneurysm patients may be as high as 50% (7). Surgical treatment of large and giant aneurysms after packing of coils within the dome is extremely challenging and often dangerous. It is true that early dome protection may be achieved with coiling at low morbidity and that early surgical morbidity is substantial with large aneurysms. However, strong consideration should still be given toward primary surgical treatment, because this may be the patient’s only chance for long-term aneurysm occlusion. This decision-making process is aided by centralization of aneurysm patients at centers with both open cerebrovascular and endovascular expertise.
When clipping cannot be performed primarily, preparation of the aneurysm neck may require cutting the coils after opening of the aneurysm sac. Cutting platinum coils can be done with Aesculap wire cutting microscissors (B. Braun, Melsungen, Germany) or the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, Colorado, USA). Standard microscissors can be used,
REFERENCES 1. Byrne JV, Sohn MJ, Molyneux AJ, Chir B: Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding. J Neurosurg 90:656-663, 1999. 2. Campi A, Ramzi N, Molyneux AJ, Summers PE, Kerr RS, Sneade M, Yarnold JA, Rischmiller J, Byrne JV: Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT). Stroke 38:1538-1544, 2007. 3. Gurian JH, Marin NA, King WA, Duckwiler GR, Guglielmi G, Vinuela F: Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization. J Neurosurg 83:843-853, 1995. 4. Henkes H, Fischer S, Liebig T, Weber W, Reinartz J, Miloslavski E, Kuhne D: Repeated endovascular coil occlusion in 350 of 2759 intracranial aneurysms: safety and effectiveness aspects. Neurosurgery 58:224-232; discussion 24-32, 2006. 5. Molyneux AK, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M, Rischmiller J, for the ISAT Collaborators: Risk of recurrent subarachnoid
482
www.SCIENCEDIRECT.com
Endovascular therapy for the treatment of cerebral aneurysms has increased in recent years (10). Although results in the surgical treatment of previously coiled aneurysms are favorable in most case series, the technical challenges faced in these cases are formidable. These surgical nuances must be discussed and taught, as these cases will only become more common in the future. And, finally, the care of aneurysm patients should be centralized. This will allow the risks associated with a complex surgical repair of a coiled aneurysm to be considered before determining the primary treatment of an aneurysm.
haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 8:427-433, 2009. 6. Nussbaum ES, Nussbaum LA: A novel aneurysm clip design for atheromatous, thrombotic, or previously coiled lesions: preliminary experience with the “compression clip” in 6 cases. Neurosurgery 67:333-341, 2010. 7. Piotin M, Blanc R, Spelle L, Mounayer C, Piantino R, Schmidt PJ, Moret J: Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke 41:110-115, 2010. 8. Pyysalo LM, Keski-Nisula LH, Niskakangas TT, Kahara VJ, Ohman JE: Long-term follow-up study of endovascularly treated intracranial aneurysms. Interv Neuroradiol 16:231-329, 2010.
10. Guglielmi G, Vineula F, Dion J, Duckwiler G: Electromthrombosis of saccular aneurysms via endovascular approach. J Neurosurg 75:8-14, 1991. 11. Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, Nakaji P, Wallace RC: The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg 119:146-157, 2013. 12. Waldron JS, Halbach VV, Lawton MT: Microsurgical management of incompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery 64: 301-315; discussion 15-17, 2009.
Citation: World Neurosurg. (2015) 83, 4:481-482. http://dx.doi.org/10.1016/j.wneu.2014.08.055 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
9. Romani R, Lehto H, Laakso A, Horcajadas A, Kivisaari R, von und zu Fraunberg M, Niemela M, Rinne J, Hernesniemi J: Microsurgery for previously coiled aneurysms: experience with 81 patients. Neurosurgery 68:140-153; discussion 53-54, 2011.
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.08.055