Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
권호 표지
DOI QR코드

DOI QR Code

Management of Recurrent Cerebral Aneurysm after Surgical Clipping : Clinical Article

  • Kim, Pius (Department of Neurosurgery, College of Medicine, Chosun University) ;
  • Jang, Suk Jung (Department of Neurosurgery, College of Medicine, Chosun University)
  • Received : 2017.06.07
  • Accepted : 2017.08.10
  • Published : 2018.03.01
Download PDF
⟨ Previous Next ⟩

Abstract

Objective : Surgical clipping of the cerebral aenurysm is considered as a standard therapy with endovascular coil embolization. The surgical clipping is known to be superior to the endovascular coil embolization in terms of recurrent rate. However, a recurrent aneurysm which is initially treated by surgical clipping is difficult to handle. The purpose of this study was to research the management of the recurrent cerebral aneurysm after a surgical clipping and how to overcome them. Methods : From January 1996 to December 2015, medical records and radiologic findings of 14 patients with recurrent aneurysm after surgical clipping were reviewed retrospectively. Detailed case-by-case analysis was performed based on preoperative, postoperative and follow-up radiologic examinations and operative findings. All clinical variables including age, sex, aneurysm size and location, type and number of applied clips, prognosis, and time to recurrence are evaluated. All patients are classified by causes of the recurrence. Possible risk factors that could contribute to those causes and overcoming ways are comprehensively discussed. Results : All recurrent aneurysms after surgical clipping were 14 of 2364 (0.5%). Three cases were males and 11 cases were females. Mean age was 52.3. At first treatment, nine cases were ruptured aneurysms, four cases were unruptured aneurysms, and one case was unknown. Locations of recurrent aneurysm were determined; anterior communicating artery (A-com) (n=7), posterior communicating artery (P-com) (n=3), middle cerebral artery (n=2), anterior cerebral artery (n=1) and basilar artery (n=1). As treatment of the recurrence, 11 cases were treated by surgical clipping and three cases were treated by endovascular coil embolization. Three cases of all 14 cases occurred in a month after the initial treatment. Eleven cases occurred after a longer interval, and three of them occurred after 15 years. By analyzing radiographs and operative findings, several main causes of the recurrent cerebral aneurysm were found. One case was incomplete clipping, five cases were clip slippage, and eight cases were fragility of vessel wall near the clip edge. Conclusion : This study revealed main causes of the recurrent aneurysm and contributing risk factors to be controlled. To manage those risk factors and ultimately prevent the recurrent aneurysm, neurosurgeons have to be careful in the technical aspect during surgery for a complete clipping without a slippage. Even in a perfect surgery, an aneurysm may recur at the clip site due to a hemodynamic change over years. Therefore, all patients must be followed up by imaging for a long period of time.

Keywords

References

  1. Ahn SS, Kim YD : Three-dimensional digital subtraction angiographic evaluation of aneurysm remnants after clip placement. J Korean Neurosurg Soc 47 : 185-190, 2010 https://doi.org/10.3340/jkns.2010.47.3.185
  2. Dandy WE : Intracranial aneurysm of the internal carotid artery: cured by operation. Ann Surg 107 : 654-659, 1938 https://doi.org/10.1097/00000658-193805000-00003
  3. Elijovich L, Higashida RT, Lawton MT, Duckwiler G, Giannotta S, Johnston SC, et al. : Predictors and outcomes of intraprocedural rupture in patients treated for ruptured intracranial aneurysms: the CARAT study. Stroke 39 : 1501-1506, 2008 https://doi.org/10.1161/STROKEAHA.107.504670
  4. Ihm EH, Hong CK, Shim YS, Jung JY, Joo JY, Park SW : Characteristics and management of residual or slowly recurred intracranial aneurysms. J Korean Neurosurg Soc 48 : 330-334, 2010 https://doi.org/10.3340/jkns.2010.48.4.330
  5. Inagawa T, Ishikawa S, Aoki H, Ishikawa S, Yoshimoto H : Aneurysmal subarachnoid hemorrhage in izumo city and shimane prefecture of Japan. Incidence. Stroke 19 : 170-175, 1988 https://doi.org/10.1161/01.STR.19.2.170
  6. Kang HS, Han MH, Kwon BJ, Jung SI, Oh CW, Han DH, et al. : Postoperative 3D angiography in intracranial aneurysms. AJNR Am J Neuroradiol 25 : 1463-1469, 2004
  7. Li H, Pan R, Wang H, Rong X, Yin Z, Milgrom DP, et al. : Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and metaanalysis. Stroke 44 : 29-37, 2013 https://doi.org/10.1161/STROKEAHA.112.663559
  8. McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, et al. : The barrow ruptured aneurysm trial. J Neurosurg 116 : 135-144, 2012 https://doi.org/10.3171/2011.8.JNS101767
  9. Papadopoulos MC, Apok V, Mitchell FT, Turner DP, Gooding A, Norris J : Endurance of aneurysm clips: mechanical endurance of yasargil and spetzler titanium aneurysm clips. Neurosurgery 54 : 966-972, 2004 https://doi.org/10.1227/01.NEU.0000116140.53925.03
  10. Rauzzino MJ, Quinn CM, Fisher WS 3rd : Angiography after aneurysm surgery: indications for "selective" angiography. Surg Neurol 49 : 32-41; discussion 40-41, 1998 https://doi.org/10.1016/S0090-3019(97)00035-9
  11. R Jabbarli, D Pierscianek, Wrede K, Dammann P, Schlamann M, Forsting M, et al. : Aneurysm remnant after clipping: the risks and consequences. J Neurosurg 125 : 1249-1255, 2016 https://doi.org/10.3171/2015.10.JNS151536
  12. Sacco RL, Wolf PA, Bharucha NE, Meeks SL, Kannel WB, Charette LJ, et al. : Subarachnoid and intracerebral hemorrhage: natural history, prognosis, and precursive factors in the Framingham Study. Neurology 34 : 847-854, 1984 https://doi.org/10.1212/WNL.34.7.847
  13. Sarti C, Tuomilehto J, Salomaa V, Sivenius J, Kaarsalo E, Narva EV, et al. : Epidemiology of subarachnoid hemorrhage in Finland from 1983-1985. Stroke 22 : 848-853, 1991 https://doi.org/10.1161/01.STR.22.7.848
  14. Sindou M, Acevedo JC, Turjman F : Aneurysmal remnants after microsurgical clipping: classification and results from a prospective angiographic study (in a consecutive series of 305 operated intracranial aneurysms). Acta Neurochir (Wien) 140 : 1153-1159, 1998 https://doi.org/10.1007/s007010050230
  15. Thornton J, Bashir Q, Aletich VA, Debrun GM, Ausman JI, Charbel FT : What percentage of surgically clipped intracranial aneurysms have residual necks? Neurosurgery 46 : 1294-1300, discussion 1298-1300, 2000 https://doi.org/10.1097/00006123-200006000-00003
  16. Tsutsumi K, Ueki K, Morita A, Usui M, Kirino T : Risk of aneurysm recurrence in patients with clipped cerebral aneurysms: results of long-term follow-up angiography. Stroke 32 : 1191-1194, 2001 https://doi.org/10.1161/01.STR.32.5.1191
  17. Tsutsumi K, Ueki K, Usui M, Kwak S, Kirino T : Risk of recurrent subarachnoid hemorrhage after complete obliteration of cerebral aneurysms. Stroke 29 : 2511-2513, 1998 https://doi.org/10.1161/01.STR.29.12.2511
  18. Washington CW, Zipfel GJ, Chicoine MR, Derdeyn CP, Rich KM, Moran CJ, et al. : Comparing indocyanine green videoangiography to the gold standard of intraoperative digital subtraction angiography used in aneurysm surgery. J Neurosurg 118 : 420-427, 2013 https://doi.org/10.3171/2012.10.JNS11818

Cited by

  1. Microsurgical Clip Suspension to Prevent Optic Neuropathy Following Ligation of Anterior Communicating Artery Aneurysm: A Technical Report and Surgical Video vol.11, pp.12, 2019, https://doi.org/10.7759/cureus.6354