Introduction: The optimal strategy for treatment of residual or recurrent aneurysms after previous coiling is unclear. We describe the results of microsurgical treatment of previously coiled cerebral aneurysms.
Methods: We examined 43 previously coiled aneurysms which were subsequently treated with open microsurgery from 2003-2015. Demographics, presentation, aneurysm characteristics, and surgical methods were analyzed. The primary outcome was postsurgical change in Glasgow Outcome Score (GOS). The secondary outcome was a composite measure of surgical or perioperative complications.
Results: The average age at surgery was 53 (28-75), and 79% of patients were women. Thirty-two patients (74%) initially presented with rupture, and the median time between initial coiling and surgery was 10 months. Thirty-one patients (72%) were smokers, 20 (47%) had previously diagnosed hypertension, 4 (9%) were diabetic, and 10 (23%) had a family history of aneurysms. Thirty-nine anterior circulation aneurysms were treated (91%), compared with 4 in the posterior circulation (9%). Extruded coils were noted in 6 patients (16%) requiring partial coil removal in one patient (3%). Bypass was utilized in one patient (3%). Three patients (7%) had a worse GOS postoperatively, and 10(23%) suffered a perioperative complication. Complications were not predicted by aneurysm size (p=0.29), posterior circulation location (p=0.23), early vs. late surgery (p=0.68), use of temporary clips (p=0.08), or intraoperative rupture (p=0.23). During the first half of the study period, 2 patients (9%) had their initial coiling at an outside hospital, compared with 8 patients (36%) in the latter half of the study (p=0.07).
Conclusions: Previously coiled patients who underwent subsequent clipping represent a challenging subset of patients, with high rates of previous hemorrhage, smoking, and family histories of aneurysms. There is a trend towards increasing numbers referred to tertiary care centers when recurrence is detected after initial coiling elsewhere.
Patient Care: This data will help evaluate the risks and benefits of microsurgical treatment for patients faced with residual or recurrent aneurysms after original coiling.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the characteristics and outcomes of patients undergoing clipping after coiling, 2)Identify changing referral patterns for management of recurrent aneurysms after previous coiling, 3) Describe different operative techniques used in post-coiling microsurgical clipping.