Tag: Clipping

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Chronic Oculomotor Nerve Palsy Presentation From Posterior Communicating Artery Aneurysm

Operative Neurosurgery 30:703–710, 2026

This case series analyzes 17 patients with subacute to chronic oculomotor nerve palsy (ONP) caused by posterior communicating artery (PCoA) aneurysms treated between 1991 and 2024. Demographics, aneurysm characteristics, treatment modalities (clipping vs endovascular), and follow-up outcomes are reported, highlighting that only a minority presented with rupture.

The report finds that complete ONP recovery occurred exclusively in patients treated within five weeks of symptom onset, supporting early definitive management to maximize functional nerve recovery despite chronic ONP not reliably predicting imminent aneurysm rupture.

Clinical question: The natural history of chronic oculomotor nerve palsy (ONP) from posterior communicating artery (PCoA) aneurysm is unclear, especially regarding rupture risk and likelihood of nerve recovery when symptoms persist beyond 1 week.

Cohort & design: Case series from a prospectively accrued institutional database (1991–2024) including patients with ≥1 week ONP attributed to PCoA aneurysm; patients with <1 week onset, inadequate follow-up, or other causes of ONP were excluded.

Patient profile: 17 patients; predominantly female (94.1%), median age 56; ONP duration ranged 1 week to 10 years; 29.4% presented with aneurysm rupture.

Treatment approaches: Most were treated with microsurgical clipping (64.7%) or endovascular therapy (29.4%); one patient was managed conservatively due to comorbidities/limited life expectancy.

ONP recovery outcomes: Complete ONP recovery occurred in 23.5% (4/17); all complete recoveries were in patients with symptom duration <5 weeks.

Timing signal: Subacute ONP (<5 weeks) was associated with better recovery (including complete recovery), while chronic ONP (≥5 weeks) had no complete recoveries in this cohort.

Rupture implication: Chronic ONP appeared not to indicate imminent rupture, with only about one-third presenting ruptured and an example of 10 years of stable ONP preceding rupture in the longest-duration case.

Management takeaway: Even if chronic ONP may not predict near-term rupture, early definitive aneurysm treatment is still recommended to maximize the chance of functional ONP recovery.

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Role of surgical treatment of intracranial aneurysms in the era of endovascular therapy: a review

Neurosurg Focus 59(6):E2, 2025

This review evaluates the contemporary role of microsurgical clipping versus endovascular treatment (EVT) for intracranial aneurysms, comparing long-term durability, complication profiles, and anatomical or patient factors that guide modality selection. It synthesizes trial data (ISAT, BRAT), meta-analyses, and location-specific outcomes to highlight differences in occlusion, retreatment, and morbidity.

The article also outlines practical considerations—hybrid strategies, cerebral bypass, training needs, economics, and global disparities—arguing for individualized, multidisciplinary decision-making and preserving microsurgical expertise despite growing EVT adoption.

Treatment Goals: Exclusion of intracranial aneurysms from circulation while preserving parent vessels and neural function remains the primary objective; both endovascular treatment (EVT) and microsurgical clipping are core modalities.

Long-term Outcomes: Microsurgical clipping offers greater durability and lower rates of recurrence, rebleeding, and retreatment compared to EVT, which has higher retreatment rates despite lower short-term morbidity.

Procedure Selection: EVT is generally preferred for older patients and posterior circulation aneurysms, while microsurgery is favored in younger patients, those with hematomas, mass effect, and aneurysms of the middle cerebral and pericallosal arteries.

Aneurysm Location: Surgical clipping achieves higher occlusion and lower recurrence, especially for anterior circulation, middle cerebral artery, and complex aneurysms; EVT is more suitable for posterior circulation and anatomically challenging cases.

Complications and Adjuncts: Microsurgery allows for evacuation of hematomas and cisternal blood (reducing vasospasm and hydrocephalus), while EVT avoids craniotomy risks but may induce mechanical vasospasm and requires antiplatelet therapy.

Hybrid and Advanced Techniques: Hybrid approaches (combining EVT and surgery) and cerebral bypass remain essential for complex, giant, or recurrent aneurysms not amenable to standard treatments.

Cost and Access: Microsurgical treatment incurs lower overall healthcare costs than EVT; global disparities exist, with surgical clipping dominating in low-resource settings due to limited endovascular infrastructure.

Decision-Making: Optimal management requires individualized, multidisciplinary evaluation considering patient factors, aneurysm characteristics, and resource availability; no single factor should solely dictate treatment choice

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Microsurgical management of 883 previously coiled intracranial aneurysms

J Neurosurg 143:654–667, 2025

This systematic review and meta-analysis found that microsurgical management of previously coiled intracranial aneurysms is effective and safe in well-selected patients, achieving high complete occlusion and good functional outcomes, especially with delayed direct clipping, small aneurysm size, and anterior location.

• Microsurgical management of previously coiled intracranial aneurysms (IAs) is effective and safe in well-selected patients.

• Meta-analysis included 874 patients with 883 previously coiled IAs; most underwent direct clipping.

• Complete occlusion rate was 97.2%, good functional outcome 82.9%, and perioperative mortality 3.7%.

• Direct clipping had the best safety and efficacy, with the lowest rates of complications and highest rates of good outcomes.

• Smaller, anteriorly located, and unruptured aneurysms were associated with the most favorable outcomes.

• Early microsurgery (within 1 month of coiling) and Gurian group C IAs had higher perioperative death rates.

• Key management factors: IA size, location, rupture status, indication, and timing/type of microsurgery.

• Most studies were retrospective case series, limiting subgroup analysis and introducing some heterogeneity.

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Open Microsurgical Versus Endovascular Management of Unruptured and Ruptured Brain Aneurysms

Operative Neurosurgery 29:171–180, 2025

This review compares open microsurgical clipping and endovascular techniques for treating unruptured and ruptured brain aneurysms, discussing their respective risks, benefits, and outcomes. It emphasizes individualized treatment decisions based on aneurysm characteristics, patient factors, and advances in both surgical and endovascular modalities.

• Microsurgical clipping and endovascular techniques are the main treatments for intracranial aneurysms, each with distinct risks and benefits.

• Clipping offers more durable repairs and lower retreatment rates but is more invasive and has higher short-term morbidity, especially in ruptured aneurysms.

• Endovascular treatments (coiling, stenting, flow diverters) are less invasive, have shorter recovery, and are preferred for older patients or those with comorbidities, but have higher recurrence and retreatment rates.

• Aneurysm characteristics such as size, location, morphology, and patient age/comorbidities are critical in selecting the optimal treatment.

• Posterior circulation aneurysms and wide-necked or complex aneurysms often favor endovascular approaches due to surgical risks.

• Clipping is particularly advantageous for younger patients, anterior circulation, and when hematoma evacuation or fenestration is needed.

• New endovascular devices (flow diverters, WEB) expand treatment options but require further study for long-term outcomes.

• Treatment decisions should be individualized, ideally at centers with expertise in both techniques, considering rupture status, anatomy, and patient factors.

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From conservative to interventional management in unruptured intracranial aneurysms

J Neurosurg 142:619–625, 2025

• Study Focus: Management of unruptured intracranial aneurysms (UIAs) from conservative to interventional.

• Objective: Identify patterns and predictors for revising UIA management strategy.

• Methodology: Retrospective review of cases diagnosed between 2006-2022 with conservative management.

• Results: 10 of 144 cases shifted to interventional treatment due to aneurysm growth.

• UIA Growth: Most frequent reason for changing treatment strategy.

• Size Threshold: UIAs > 3 mm at diagnosis more likely to require intervention.

• Conservative Management: Regular radiographic follow-ups recommended, especially for UIAs > 3 mm.

• Guidelines: ESO and American Heart Association guidelines emphasize monitoring UIA growth.

• Statistical Analysis: Cox regression and Kaplan-Meier curves used for data analysis.

• Risk Factors: No significant effect of potential risk factors on treatment change.

• Imaging: DSA as confirmative modality for revising conservative management.

• Study Limitations: Low statistical power due to limited cases of treatment change.

• Conclusion: Regular monitoring crucial for conservatively managed UIAs, especially > 3 mm.

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Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use?

Operative Neurosurgery 27:581–596, 2024

Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era.

METHODS: This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis.

RESULTS: Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction.

CONCLUSION: These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.

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Incidence and Characteristics of Cerebral Infarction After Microsurgical Clipping of Unruptured Anterior Circulation Cerebral Aneurysms

Neurosurgery 95:798–806, 2024

Postclipping cerebral infarction (PCI) remains a major concern after treatment for unruptured intracranial aneurysms (UIAs). However, studies of microsurgical clipping based on diffusion-weighted imaging are limited. We aimed to present the incidence, risk factors, and types of PCI and its radiological and clinical characteristics.

METHODS: This was a retrospective single-center study in which patients were scheduled to undergo microsurgical clipping for anterior circulation UIAs. The overall incidence and risk factors were calculated. Based on the operation and relevant artery, we categorized PCI on diffusion-weighted imaging into 4 types and presented their radiological and clinical characteristics.

RESULTS: We reviewed the radiological and clinical data of 605 patients. The overall incidence of PCI was 16.7% (101/ 605), of which asymptomatic infarction was 14.9% (90/605) and symptomatic infarction was 1.8% (11/605). Hypertension (adjusted odds ratio [aOR], 2.258; 95% confidence interval [CI]: 1.330-3.833), temporary clipping (aOR, 1.690; 95% CI: 1.034-2.760), multiple aneurysm locations (aOR, 1.832; 95% CI: 1.084-3.095), and aneurysm dome size (aOR, 1.094; 95% CI: 1.006-1.190) were independent risk factors for PCI. Type II (perianeurysmal perforator) infarction was the most common type of PCI (48.6%) and the most common cause of symptomatic infarction (72.7%). Types II and III (distal embolic) infarctions correlated with atherosclerotic changes in the aneurysm wall and temporary clipping (62.4% and 70.6%, respectively). The type IV (unrelated) infarction group had a higher incidence of systemic atherosclerosis (55%).

CONCLUSION: Microsurgical clipping is a safe and viable option for the treatment of anterior circulation UIAs. However, modification of the surgical technique, preoperative radiological assessment, and patient selection are required to reduce the incidence of PCI.

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Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms—A Global Multicenter Investigation of Perioperative Outcomes

Neurosurgery 94:1218–1226, 2024

Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms.

METHODS: Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics.

RESULTS: Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers.

CONCLUSION: Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

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The learning curve for cavernous sinus surgery illustrated by symptomatic intracavernous aneurysm clipping through a pretemporal transcavernous approach

J Neurosurg 140:183–193, 2024

OBJECTIVE The anatomy of the cavernous sinus (CS) has been well studied in the laboratory for decades; however, performing surgery in and around the CS is still a challenge. To reveal the learning curve for CS surgery via the pretemporal transcavernous approach (PTTC), surgical procedures were examined. The authors proposed 4 levels of surgical difficulty in opening the walls of the CS through this approach. Details of the approach were illustrated by surgical videos of symptomatic intracavernous aneurysm clipping.

METHODS Four levels of surgical difficulty were proposed. The higher the level, the more the CS walls were opened. Pathologies corresponding to each level of difficulty in and around the CS were categorized in each level together with explanations. From 2015 to 2021, 5 patients with symptomatic intracavernous aneurysms (diplopia due to compressive cranial neuropathy) underwent the PTTC at the authors’ institute and served as representative cases in opening the walls of the CS. All CS cases from 2009 to 2021 were reviewed and categorized to demonstrate the learning curve.

RESULTS Four levels of surgical difficulty are as follows: level 1, a basic Dolenc extradural approach, which involves opening the anterior third of the superior and lateral walls of the CS; level 2, mobilizing the internal carotid artery (ICA) and opening the proximal dural ring to enter the roof of the CS and treat lesions around the clinoid and upper cavernous ICA; level 3, opening the entire aspect of the superior and lateral walls of the CS, which involves opening the oculomotor triangle and peeling the lateral wall of the CS to the tentorial incisura; and level 4, mobilizing cranial nerves III, IV, and V1 to gain access to the supra-/infratrochlear triangles to have proximal ICA control and opening the posterior wall as the last step to enter the posterior fossa. Surgical steps were described and illustrated with surgical videos of symptomatic intracavernous aneurysm clipping.

CONCLUSIONS The learning curve for CS surgery is long. The authors use 4 levels of surgical difficulty to describe applications of the PTTC in CS surgery. This approach serves as an effective workhorse in treating CS pathologies with low morbidity and high success rates when performed by experienced neurosurgeons.

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Preoperative Microsoft HoloLens 2 planning‑assisted surgical clipping of a fetal posterior cerebral artery aneurysm

Acta Neurochirurgica (2023) 165:3371–3374

The treatment of intracranial aneurysms has predominantly shifted towards endovascular strategies, but complex cases still necessitate microsurgery. Preoperative stimulation can be beneficial for inexperienced young neurosurgeons in preparing for safe microsurgery.

Method A 72-year-old female with a left irregular fetal posterior cerebral artery (PCA) aneurysm underwent clipping repair. Microsoft HoloLens 2, utilizing mixed reality technology, was employed for preoperative stimulation and anatomical study. During the operation, we successfully identified the planned relationship between the aneurysm and the fetal PCA. The patient was cured without any complications.

Conclusion We hope that this report will highlight the significance of Microsoft HoloLens 2 in microsurgical planning and education.

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Endoscopic clipping of an anterior communicating artery aneurysm

Acta Neurochirurgica (2023) 165:1227–1231

Anterior communicating artery aneurysms are most prone to rupture. Surgically, they are conventionally being managed by a pterional approach. Some neurosurgeons prefer a supraorbital keyhole approach in select cases. Fully endoscopic clipping of such aneurysms is seldom described.

Method We clipped an antero-inferiorly directed anterior communicating artery aneurysm endoscopically via a supraorbital keyhole approach. The intraoperative aneurysmal rupture was also managed endoscopically. The patient made an excellent postoperative recovery without any neurological deficits.

Conclusion Select cases of anterior communicating artery aneurysms can be clipped endoscopically using standard instruments and adhering to the basic principles of aneurysm clipping.

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Risk of intracranial aneurysm recurrence after microsurgical clipping based on 3D digital subtraction angiography

J Neurosurg 138:717–723, 2023

Current knowledge of recurrence rates after intracranial aneurysm (IA) surgery relies on 2D digital subtraction angiography (DSA), which fails to detect more than 75% of small aneurysm remnants. Accordingly, the discrimination between recurrence and growth of a remnant remains challenging, and actual assessment of recurrence risk of clipped IAs could be inaccurate. The authors report, for the first time, 3D-DSA–based long-term durability and risk factor data of IA recurrence and remnant growth after microsurgical clipping.

METHODS Prospectively collected data for 305 patients, with a total of 329 clipped IAs that underwent baseline 3DDSA, were evaluated. The incidence of recurrent IA was described by Kaplan-Meier curves. Risk factors for IA recurrence were analyzed by multivariable Cox proportional hazards and logistic regression models.

RESULTS The overall observed proportion of IA recurrence after clipping was 2.7% (9 of 329 IAs) at a mean followup of 46 months (0.7% per year). While completely obliterated IAs did not recur during follow-up, incompletely clipped aneurysms (76 of 329) demonstrated remnant growth in 11.8% (3.4% per year). Young age and large initial IA size significantly increased the risk of IA recurrence.

CONCLUSIONS The findings support those in previous studies that hypothesized that completely clipped IAs have an extremely low risk of recurrence. Conversely, the results highlight the significant risk posed by incompletely clipped IAs. Young patients with initial large IAs and incomplete obliteration have an especially high risk for IA recurrence and therefore should be monitored more closely.

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Helsinki style mini‑pterional craniotomy for clipping of middle cerebral artery bifurcation aneurysms

Acta Neurochirurgica (2023) 165:489–493

Different versions of the mini-pterional (MPT) approach have been described often with the idea the smaller the better. Attempts to reduce incision and craniotomy size for better cosmetic results should not be performed at the expense of safety.

Method We present our take on the MPT as a balance between size and safety which can be adopted by vascular neurosurgeons in training. The craniotomy stays within the confines of the superior temporal line and is completely covered by temporal muscle after closure.

Conclusion This approach is cosmetically superior while still offering anatomical familiarity and sufficient instrument maneuverability.

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Woven Endobridge Embolization Versus Microsurgical Clipping for Unruptured Anterior Circulation Aneurysms

Neurosurgery 88:779–784, 2021

Intrasaccular flow-disruption represents a new paradigmin endovascular treatment of wide-necked bifurcation aneurysms.

OBJECTIVE: To retrospectively compare Woven Endobridge (WEB) embolization with microsurgical clipping for unruptured anterior circulation aneurysms using propensity score adjustment.

METHODS: A total of 63 patients treated with WEB and 103 patients treated with clipping were compared based on the intention-to-treat principle. The primary outcome measures were immediate technical treatment success, major adverse events, and 6-mo complete aneurysm occlusion.

RESULTS: The technical success rates were 83% forWEB and 100% for clipping. Procedure related complications occurred more often in the clipping group (13%) than the WEB group (6%, adjusted P<.01). However, the rates of major adverse events were comparable in both groups (WEB: 3%, clip: 4%, adjusted P = .53). At the 6-mo follow-up, favorable functional outcomes were achieved in 98% of the WEB embolization group and 99% of the clipping group (adjusted P = .19). Six-month complete aneurysm occlusion was obtained in 75% of the WEB group and 94% of the clipping group (adjusted P < .01).

CONCLUSION: Microsurgical clipping was associated with higher technical success and complete occlusion rates, whereas WEB had a lower complication rate. Favorable functional outcomes were achieved in≥98% of both groups. The decision to use a specific treatment modality should be made on an individual basis and in accordance with the patient’s preferences.

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Lateral supra-cerebellar infra-tentorial approach for P2-P3 junction cerebral aneurysms

Acta Neurochirurgica (2020) 162:2767–2772

P2-P3 junction aneurysms are challenging to treat surgically because of their frequent complex morphology and their location deep in close proximity to the midbrain. The sub-temporal route requires significant retraction of the temporal lobe in addition to potential injury to the vein of Labbe.

We describe the technique for treating such aneurysms via a lateral supra-cerebellar infratentorial (LSCIT) approach, which eliminates manipulation of the temporal lobe.

Method Cadaveric dissection provided comprehensive understanding of relevant anatomy. Intraoperative video shows clipping of the aneurysm using a LSCIT approach.

Conclusion LSCIT approach allows safe clipping of P2-P3 aneurysms with minimal brain manipulation.

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Outcomes of Retreatment for Intracranial Aneurysms—A Meta-Analysis

Neurosurgery. 2019 Dec 1;85(6):750-761

Long-term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment.

OBJECTIVE: To evaluate retreatment related outcomes.

METHODS: A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias.

RESULTS: Twenty-five articles that met the inclusion criteria were included in the metaanalysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95% confidence interval [CI]: 87.0-94.1) and a pooled mortality rate of 5.6% (95% CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95% CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95% CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95% CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95% CI: 11.4-92.7) and a pooled mortality rate of 9.3% (95% CI: 4.1- 19.9). All pooled incidence rates were produced using random-effect models.

CONCLUSION: Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate.

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Indocyanine green fluorescence video angiography reduces vascular injury–related morbidity during micro-neurosurgical clipping of ruptured cerebral aneurysms: a retrospective observational study

Acta Neurochirurgica (2019) 161:2397–2401

Specific procedural complications in aneurysm surgery are broadly related to vascular territory compromise and brain/nerve retraction; vascular complications account for about half of this. Intraoperative indocyanine green video angiography (ICG-VA) provides real-time high spatial resolution imaging of the cerebrovascular architecture, allowing immediate quality assurance of aneurysm occlusion and vessel integrity. The aim of this study was to examine whether the routine use of ICG-VA reduced early procedural complications related to vascular compromise or injury during micro-neurosurgical clipping of ruptured cerebral aneurysms.

Methods Retrospective comparative observational study of 412 adult good-grade (WFNS 1 or 2) SAH patients who had undergone microsurgical clipping without (n = 200, 2001–2004) or with (n = 212, 2009–2015) ICG-VA in a high-volume neurosurgical centre.

Results The ICG-VA group had a significantly lower incidence of procedural vascular complications (7/212; 3.3%) compared with the non-ICG-VA group (19/200; 9.5%) (Fisher’s exact test p = 0.0137).

Conclusions ICG-VA is a straightforward, easy-to-use, intraoperative adjunct which significantly reduces avoidable ‘technical error’ related morbidity.

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Management of recurrent intracranial aneurysms after coil embolization: a novel classification scheme based on angiography

J Neurosurg 131:1455–1461, 2019

Recurrent aneurysms after coil embolization remain a challenging issue. The goal of the present study was to report the authors’ experience with recurrent aneurysms after coil embolization and to discuss the radiographic classification scheme and recommended management strategy.

METHODS Aneurysm treatments from a single institution over a 6-year period were retrospectively reviewed. Ninetyseven aneurysms that recurred after initial coiling were managed during the study period. Recurrent aneurysms were classified into the following 5 types based on their angiographic characteristics: I, pure recanalization inside the aneurysm sac; II, pure coil compaction without aneurysm growth; III, new aneurysm neck formed without coil compaction; IV, new aneurysm neck formed with coil compaction; and V, newly formed aneurysm neck and sac.

RESULTS Aneurysm recurrences resulted in rehemorrhages in 6 cases (6.2%) of type III–V aneurysms, but in none of type I–II aneurysms. There was a significantly higher proportion of ophthalmic artery aneurysms and complex internal carotid artery aneurysms presenting as types I and II than presented as the other 3 types (63.3% vs 16.4%, p < 0.001). In contrast, for posterior communicating artery aneurysms and anterior communicating artery aneurysms, a higher proportion of type III–V aneurysms was observed than for the other 2 types, but without a significant difference in the multivariate model (56.7% vs 23.3%). In addition, giant (> 25 mm) aneurysms were more common among type I and II lesions than among type III and IV aneurysms (36.7% vs 9.0%, p = 0.001), which exhibited a higher proportion of small (< 10 mm) lesions (65.7% vs 13.3%, p < 0.001). A single reembolization procedure was sufficient to occlude 80.0% of type I recurrences and 83.3% of type II recurrences from coil compaction but only 65.6% of type III–V recurrences from aneurysm regrowth.

CONCLUSIONS Aneurysm size and location represent the determining factors of the angiographic recurrence types. Type I and II recurrences were safely treated by reembolization, whereas type III–V recurrences may be best managed surgically when technically feasible.

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Endoscopic clipping of intraventricular aneurysms using the “wet-field” technique

J Neurosurg 131:104–108, 2019

Intraventricular hemorrhage and intracerebral aneurysms are relatively frequent complications associated with moy- amoya disease. Prevention of aneurysm rerupture is important because it significantly decreases the morbidity and mortality rates. Aneurysms arising distal to collateral flow are sometimes observed in patients with intraventricular hem- orrhage; however, the treatment of these aneurysms remains challenging because of their deep-seated location in the brain and accompanying narrow surgical corridor.

The authors describe a neuroendoscopic aneurysm clipping technique performed in 2 cases using a small-diameter tubular retractor for intraventricular aneurysms of the distal lateral posterior choroidal artery. In this technique, the surgical field was continuously irrigated with artificial CSF to keep the ventricle size intact, and aneurysm clipping was performed through a tubular retractor that was introduced with neuronavigational guidance. The patients’ postoperative courses were uneventful, and CT angiography revealed complete clipping of the aneurysms and patent parent arteries.

Endoscopic clipping using a tubular retractor is an effective and less invasive alternative for treating intraventricular aneurysms. The wet-field endoscopic technique is performed in an aqueous field and maintains an intact ventricle size, allowing for a clear surgical view and a wider, enhanced surgical field.

 

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Outcome After Clipping and Coiling for Aneurysmal Subarachnoid Hemorrhage in Clinical Practice in Europe, USA, and Australia

Neurosurgery 84:1019–1027, 2019

Within randomized clinical trials (RCTs), coiling of the ruptured aneurysm to prevent rebleeding results in better outcomes than clipping in patients with aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVE: To study the association of coiling and clipping with outcome after aSAH in daily clinical practice.

METHODS: In this controlled, nonrandomized study, we compared outcomes after endovascular coiling and neurosurgical clipping of ruptured intracranial aneurysms in an administrative dataset of 7658 aSAH patients (22 tertiary care hospitals from Europe, USA, Australia; 2007-2013). Because the results contradicted those of the randomized trials, findings were further explored in a large clinical dataset from 2 European centers (2006- 2016) of 1501 patients.

RESULTS: In the administrative dataset, the crude 14-d case-fatality rate was 6.4% (95% confidence interval [CI] 5.6%-7.2%) after clipping and 8.2% (95% CI 7.4%-9.1%) after coiling. After adjustment for age, sex, and comorbidity/severity, the odds ratio (OR) for 14-d casefatality after coiling compared to clipping was 1.32 (95% CI 1.10-1.58). In the clinical dataset crude 14-d case fatality ratewas 5.7% (95% CI 4.2%-7.8%) for clipping and 9.0% (95% CI 7.3%- 11.2%) for coiling. In multivariable logistic regression analysis, the OR for 14-d case-fatality after coiling compared to clipping was 1.7 (95% CI 1.1–2.7), for 90-d case-fatality 1.28 (95% CI 0.91–1.82) and for 90-d poor functional outcome 0.78 (95% CI 0.6–1.01).

CONCLUSION: In clinical practice, coiling after aSAH is associated with higher 14-d case-fatality than clipping and nonsuperior outcomes at 90 d. Both options need to be considered in aSAH patients. Further studies should address the reasons for the discrepancy between current data and those from the RCTs.

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