Introduction: Endovascular and surgical techniques are recognized options for aneurysm treatment. Both modalities employed in tandem on single patients are efficacious, achieving durable aneurysm occlusion(s) and good patient outcomes. Indications, sequencing rationale and categorization for single patient multimodality treatment are reviewed.
Methods: Aneurysms treated from 2004 through 2014 were reviewed. Patients were included in our analysis when endovascular and surgical modalities were used on single patients. Endovascular treatment included: coiling, balloon-assisted coiling, stenting, or parent vessel occlusion (PVO). Angioplasty was excluded. Surgical treatments included: clipping, attempted clipping, decompressive craniectomy, and bypass. EVDs and shunts were excluded. Demographics, presentation data, locations, size, treatment sequencing, and outcomes were assessed.
Results: 1493 aneurysms were treated between 2004-2014. 30 patients met our definition of multimodality treatment. Mean age was 54.3. 69% were females. 73% had SAH. Categorization was as follows (Table-1): 17 had clipping and coiling (CL+CO), 5 had clipping and stenting (CL+ST), 3 had bypass and endovascular (PVO) (BY+PVO), 2 had decompressive crainectomy and coiling, 1 had attempted clipping then stenting, 1 had decompression followed by PVO, and 1 had bypass followed by stenting. The CL+CO group was divided into four categories (Table-2): initial clipping followed by coiling of a different aneurysm (CL-CO-Multiple): 6 patients, initial coiling with clipping of a different aneurysm (CO-CL-Multiple): 4 patients, clipping followed by coiling of residual/recanalized aneurysm (CL-CO-Single): 3 patients, and coiling followed by clipping for residual/ recanalized aneurysm (CO-CL-Single): 5 patients. All stenting patients had surgical intervention prior to stenting. GOS was: CL-CO-Multiple: 4.2, CO-CL-Multiple: 4, CL-CO-Single: 3, CO-CL-Single: 5. Stenting patients had a GOS of 4.8. Bypass patients had GOS of 4. There were 3 mortalities.
Conclusions: Single patient multimodality aneurysm treatment is a safe and effective paradigm for treating patients with multiple or complex aneurysms. With appropriate patient selection and treatment sequencing, good outcomes are achieved.
Patient Care: By understanding the ideal sequence of treatment, which will lead to complete aneurysm occlusion and more patients' safety.
Learning Objectives: To understand the appropriate sequence of multi modality treatment for cerebral aneurysms.