J Korean Neurosurg Soc.  2018 Mar;61(2):212-218. 10.3340/jkns.2017.0506.009.

Management of Recurrent Cerebral Aneurysm after Surgical Clipping : Clinical Article

Affiliations
  • 1Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea.

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.

Keyword

Recurrence; Aneurysm; Clips

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Anterior Cerebral Artery
Arteries
Basilar Artery
Embolization, Therapeutic
Female
Follow-Up Studies
Hemodynamics
Humans
Intracranial Aneurysm*
Male
Medical Records
Middle Cerebral Artery
Neurosurgeons
Prognosis
Recurrence
Retrospective Studies
Risk Factors
Surgical Instruments*

Figure

  • Fig. 1 Case 5. Images providing an example of a recurrent aneurysm due to fragility of vessel wall. This patient with a dog ear formation (white arrow) right beside previous clips (black arrow) demonstrated by the preoperative DSA (A). The patient underwent a craniotomy for aneurysm clipping. There was a tough adherent connective tissue between the clips and aneurysm wall (B). A delicate dissection avoiding aneurysm rupture and unclipping was done. Then, the recurrent aneurysm was completely ligated by cotton-clipping technique (C). The postoperative DSA demonstrated a complete clipping (D). DSA : digital subtraction angiography.

  • Fig. 2 Case 10. Images providing an example of a recurrent aneurysm due to incomplete clipping. The patient presented with ruptured aneurysm on anterior cerebral artery (white arrow) underwent a surgical clipping (A). Contrary to post-operative computed tomography angiography image after the first clipping (B), the DSA after recurrent subarachnoid hemorrhage demonstrated a displacement of the clips from the aneurysm (C). The patient then underwent surgical revision, and the aneurysm was clipped again with an additional clip. Finally, post-operative DSA confirmed the complete ligation (D) and recurrence did not occur during the follow up period. DSA : digital subtraction angiography.

  • Fig. 3 An example showing usefulness of intraoperative videoangiography. A 63-years-old female patient with a ruptured aneurysm on middle cerebral arterial bifurcation underwent craniotomy and clip ligation (A and B). Following intraoperative videoangiography with indocyanine green showed blood flow that remained inside the aneurysm indicating incomplete obliteration (C, arrowhead). Therefore, an additional clip was immediately applied to the aneurysm. The fluorescein videoangiography was subsequently performed in few minutes and finally, during surgery, the complete obliteration was confirmed (D).

  • Fig. 4 A figure demonstrating a temporal distribution of recurrences from initial clipping.


Reference

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.
Article
2. Dandy WE. Intracranial aneurysm of the internal carotid artery: cured by operation. Ann Surg. 107:654–659. 1938.
Article
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.
Article
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.
Article
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.
Article
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 meta-analysis. Stroke. 44:29–37. 2013.
Article
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.
Article
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.
Article
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.
Article
11. Jabbarli R, Pierscianek D, Wrede K, Dammann P, Schlamann M, Forsting M, et al. Aneurysm remnant after clipping: the risks and consequences. J Neurosurg. 125:1249–1255. 2016.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
Full Text Links
  • JKNS
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr