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Management of Residual and Recurrent Aneurysms After Initial Endovascular Treatment

Dorfer, Christian MD; Gruber, Andreas MD; Standhardt, Harald MD; Bavinzski, Gerhard MD; Knosp, Engelbert MD

doi: 10.1227/NEU.0b013e3182350da5
Research-Human-Clinical Studies

BACKGROUND: Coil instability possibly translating into higher delayed rebleeding rates remains a concern in the endovascular management of cerebral aneurysms.

OBJECTIVE: To report on 127 patients with endovascular aneurysmal remnants who underwent re-treatment over an 18 year period.

METHODS: Patients presenting with aneurysm residuals >20% of the original lesion, unstable neck remnants, aneurysmal regrowth, or new aneurysmal daughter sacs were treated by an individualized approach, using both endovascular and surgical techniques.

RESULTS: Seventy-five aneurysmal remnants (59.1%) were treated by further re-embolization. Standard coil embolization was used in 65 cases, stent-protected coiling in 9 cases, and balloon remodeled coiling in 1 case, respectively. Fifty-two (40.9%) aneurysmal remnants were treated surgically. Standard microsurgical clipping was used in 44 patients, parent artery occlusion or trapping under bypass protection in 5 cases, deliberate clipping of the basilar artery trunk in 2 cases, and aneurysm wrapping in one case, respectively. Mechanisms of aneurysm recurrence were coil compaction in 93 cases and regrowth in 34 cases. A single reembolization was sufficient to occlude 78.7% of recurrences from coil compaction, but only 14.3% of recurrences from aneurysm regrowth.

CONCLUSION: The individualized approach resulted in complete occlusion of 114 aneurysms (89.7%), with neck remnants and residual aneurysms detectable in 11 (8.7%) and 2 (1.6%) cases, respectively. Treatment morbidity was 11.9%, without significant differences between surgical (15.6%) and endovascular (9.3%) patients (P = .09). Recurrences from coil compaction were safely treated by re-embolization, whereas recurrences from aneurysmal regrowth may best be managed surgically when technically feasible.

Medical University of Vienna, Department of Neurosurgery, Waehringer Guertel, Vienna, Austria

Correspondence: Christian Dorfer, MD, Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria. E-mail: christian.dorfer@meduniwien.ac.at

* These authors have contributed equally to this article.

Received February 10, 2011

Accepted July 26, 2011

Copyright © by the Congress of Neurological Surgeons