In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Surgical Treatment of Previously Coiled Aneurysms: Meta-analysis of 466 Patients

    Final Number:

    Ondra Petr MD; Waleed Brinjikji BS; Claudius Thome MD; Giuseppe Lanzino MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: Recurrence of the aneurysm after coil embolization is not infrequent and surgical treatment of previously coiled aneurysms is necessary in some patients. The best neurosurgical strategy and technique continues to be debated. We conducted a systematic review of the literature to evaluate the safety and efficacy of surgical treatment of previously coiled aneurysms.

    Methods: Comprehensive review of the literature for studies on surgical treatment of previously coiled aneurysms. For each study, the following data were extracted: patient demographics, initial clinical status, location and size of aneurysms, time interval between initial/last endovascular procedure and surgery, surgical indications and microsurgical technique. We performed subgroup analyses to compare direct clipping versus coil removal and clipping versus parent vessel occlusion, early (<4 weeks post-coiling) versus late surgery and anterior versus posterior circulation.

    Results: 26 studies with 466 patients and 471 intracranial aneurysms were included. Patients undergoing direct clipping had lower perioperative morbidity (5.0%, 95%CI=2.6%-7.4%) when compared to those undergoing coil removal and clipping (11.1%, 95%CI=5.3%-17.0%) or parent vessel occlusion (13.1%, 95%CI=4.6%-21.6%) (P=0.05). Patients receiving early surgery (<4 weeks post-coiling) had significantly lower rates of good neurological outcome (77.1%, 95%CI=69.3%-84.8%) when compared to those undergoing late surgery (92.1%, 95%CI=89.0%-95.2%) (P<0.01). There were higher rates of long-term neurological morbidity in posterior circulation group (23.1% versus 4.7%, P<0.01) as well as long-term neurological mortality (4.4% versus 2.8%, P<0.01).

    Conclusions: Our meta-analysis demonstrated that surgical treatment is safe and effective. Our data suggest that direct clipping is superior to other surgical techniques. Late surgery was also associated with superior clinical outcomes. Surgery of recurrent posterior circulation aneurysms was associated with high rates of morbidity and mortality.

    Patient Care: Our study is the first meta-analysis studying outcomes of surgical treatment of previously coiled aneurysms. Because of the large sample size, we were able to compare outcomes by aneurysm location, rupture status, type of surgery and timing of surgery and make a number of important conclusions. Other strengths of our study include the following: following an a priori established protocol, the comprehensive literature search that involves multiple databases, and the process of study selection that was performed by independent reviewers thus fulfilling the PRISMA guidelines. We acknowledge that our meta-analysis has limitations. The methodologic quality of the studies included was variable. Surgical indications, primary clinical status and outcome assessment differed across studies. Yet, the finding that all studies produced consistent results and described similar surgical experience and postoperative outcomes reassures us that these methodologic differences do not negate the validity of the meta-analysis.

    Learning Objectives: Surgical Strategies and Outcomes in Patients with Previously Coiled Aneurysms

    References: 1. Investigators C. Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment. Stroke. 2006;37:1437-1442 2. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P, International Subarachnoid Aneurysm Trial Collaborative G. International subarachnoid aneurysm trial (isat) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366:809-817 3. Gurian JH, Martin NA, King WA, Duckwiler GR, Guglielmi G, Vinuela F. Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization. J Neurosurg. 1995;83:843-853 4. Minh T, Hwang PYK, Nguyen KC, Ng I. Neurosurgical management of intracranial aneurysms following unsuccessful or incomplete endovascular therapy. Br J Neurosurg. 2006;20:306-311 5. Romani R, Lehto H, Laakso A, Horcajadas A, Kivisaari R, Von Und Zu Fraunberg M, Niemelä M, Rinne J, Hernesniemi J. Microsurgery for previously coiled aneurysms: Experience with 81 patients. Neurosurgery. 2011;68:140-153 6. Dorfer C, Gruber A, Standhardt H, Bavinzski G, Knosp E. Management of residual and recurrent aneurysms after initial endovascular treatment. Neurosurgery. 2012;70:537-553 7. Waldron JS, Halbach VV, Lawton MT. Microsurgical management of incompletely coiled and recurrent aneurysms: Trends, techniques, and observations on coil extrusion. Neurosurgery. 2009;64:301-315; discussion 315-307 8. Raftopoulos C, Vaz G, Docquier M, Goffette P, Interventional Cerebrovascular Group UCdL. Neurosurgical management of inadequately embolized intracranial aneurysms: A series of 17 consecutive cases. Acta Neurochir (Wien). 2007;149:11-19; discussion 18-19 9. Chung J, Lim YC, Kim BS, Lee D, Lee KS, Shin YS. Early and late microsurgical clipping for initially coiled intracranial aneurysms. Neuroradiology. 2010;52:1143-1151 10. Lejeune JP, Thines L, Taschner C, Bourgeois P, Henon H, Leclerc X. Neurosurgical treatment for aneurysm remnants or recurrences after coil occlusion. Neurosurgery. 2008;63:684-691; discussion 691-682 11. Civit T, Auque J, Marchal JC, Bracard S, Picard L, Hepner H. Aneurysm clipping after endovascular treatment with coils: A report of eight patients. Neurosurgery. 1996;38:955-960; discussion 960-951 12. Horowitz M, Purdy P, Kopitnik T, Dutton K, Samson D. Aneurysm retreatment after guglielmi detachable coil and nondetachable coil embolization: Report of nine cases and review of the literature. Neurosurgery. 1999;44:712-719 13. Conrad MD, Pelissou-Guyotat I, Morel C, Madarassy G, Schonauer C, Deruty R. Regrowth of residual ruptured aneurysms treated by guglielmi's detachable coils which demanded further treatment by surgical clipping: Report of 7 cases and review of the literature. Acta Neurochir. 2002;144:419-426 14. Tirakotai W, Sure U, Yin Y, Benes L, Schulte DM, Bien S, Bertalanffy H. Surgery of intracranial aneurysms previously treated endovascularly. Clin Neurol Neurosurg. 2007;109:744-752 15. Kumar R, Deopujari CE, Shah R, Luhana R. Surgical management of intracranial aneurysms previously treated with endovascular therapy. Neurol India. 2010;58:292-297 16. Izumo T, Matsuo T, Morofuji Y, Hiu T, Horie N, Hayashi K, Nagata I. Microsurgical clipping for recurrent aneurysms after initial endovascular coil embolization. World Neurosurg. 2014 17. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177-188 18. Altman DG, Bland JM. Interaction revisited: The difference between two estimates. Bmj. 2003;326:219 19. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Bmj. 2003;327:557-560 20. Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment. Stroke. 2006;37:1437-1442 21. White PM, Lewis SC, Gholkar A, Sellar RJ, Nahser H, Cognard C, Forrester L, Wardlaw JM. Hydrogel-coated coils versus bare platinum coils for the endovascular treatment of intracranial aneurysms (helps): A randomised controlled trial. Lancet. 2011;377:1655-1662 22. Ringer AJ, Rodriguez-Mercado R, Veznedaroglu E, Levy EI, Hanel RA, Mericle RA, Lopes DK, Lanzino G, Boulos AS. Defining the risk of retreatment for aneurysm recurrence or residual after initial treatment by endovascular coiling: A multicenter study. Neurosurgery. 2009;65:311-315 23. Sluzewski M, van Rooij WJ, Beute GN, Nijssen PC. Late rebleeding of ruptured intracranial aneurysms treated with detachable coils. AJNR Am J Neuroradiol. 2005;26:2542-2549 24. Veznedaroglu E, Benitez RP, Rosenwasser RH. Surgically treated aneurysms previously coiled: Lessons learned.[reprint in neurosurgery. 2008 jun;62(6 suppl 3):1516-24; pmid: 18695572]. Neurosurgery. 2004;54:300-303; discussion 303-305 25. Asgari S, Doerfler A, Wanke I, Schoch B, Forsting M, Stolke D. Complementary management of partially occluded aneurysms by using surgical or endovascular therapy. J Neurosurg. 2002;97:843-850 26. Krishna C, Sonig A, Natarajan SK, Siddiqui AH. The expanding realm of endovascular neurosurgery: Flow diversion for cerebral aneurysm management. Methodist Debakey Cardiovasc J. 2014;10:214-219 27. Chalouhi N, Zanaty M, Whiting A, Yang S, Tjoumakaris S, Hasan D, Starke RM, Hann S, Hammer C, Kung D, Rosenwasser R, Jabbour P. Safety and efficacy of the pipeline embolization device in 100 small intracranial aneurysms. J Neurosurg. 2015;30:1-5 28. Konig RW, Kretschmer T, Antoniadis G, Seitz K, Braun V, Richter HP, Perez de Laborda M, Scheller C, Borm W. Neurosurgical management of previously coiled recurrent intracranial aneurysms. Zentralbl Neurochir. 2007;68:8-13 29. Klein O, Colnat-Coulbois S, Civit T, Auque J, Bracard S, Pinelli C, Marchal JC. Aneurysm clipping after endovascular treatment with coils: A report of 13 cases. Neurosurg Rev. 2008;31:403-410; discussion 410-401 30. Nakamura M, Montibeller GR, Gotz F, Krauss JK. Microsurgical clipping of previously coiled intracranial aneurysms. Clin Neurol Neurosurg. 2013;115:1343-1349 31. Boet R, Poon WS, Yu SC. The management of residual and recurrent intracranial aneurysms after previous endovascular or surgical treatment--a report of eighteen cases. Acta Neurochir. 2001;143:1093-1101 32. Thornton J, Aletich VA, Debrun GM, Alazzaz A, Misra M, Charbel F, Ausman JI. Endovascular treatment of paraclinoid aneurysms. Surg Neurol. 2000;54:288-299 33. Zhang YJ, Barrow DL, Cawley CM, Dion JE. Neurosurgical management of intracranial aneurysms previously treated with endovascular therapy. Neurosurgery. 2003;52:283-293; discussion 293-285 34. Nomura M, Kida S, Uchiyama N, Yamashima T, Yamashita J, Yoshikawa J, Matsui O. Aneurysm clipping after partial endovascular embolization for ruptured cerebral aneurysms. Interv Neuroradiol. 2000;1:49-58 35. Raymond J, Guilbert F, Metcalfe A, Gevry G, Salazkin I, Robledo O. Role of the endothelial lining in recurrences after coil embolization: Prevention of recanalization by endothelial denudation. Stroke. 2004;35:1471-1475 36. Coil embolization for intracranial aneurysms: An evidence-based analysis. Ont Health Technol Assess Ser. 2006;6:1-114

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy