Elsevier

World Neurosurgery

Volume 93, September 2016, Pages 341-345
World Neurosurgery

Original Article
Pipeline Embolization Device for Recurrent Cerebral Aneurysms after Microsurgical Clipping

https://doi.org/10.1016/j.wneu.2016.06.065Get rights and content

Background

Microsurgical clipping is regarded as the most durable treatment for cerebral aneurysms. Aneurysm recurrence after clipping is uncommon and is associated with an increased risk of rupture. Reoperation for recurrent cerebral aneurysms is particularly challenging because of adhesions and scaring, and it carries a higher rate of morbidity and mortality. Pipeline embolization as a treatment option for recurrent aneurysms has rarely been reported.

Methods

A retrospective analysis of patients who underwent Pipeline Embolization Device (PED) placement for recurrent aneurysms after clipping at two major academic institutions in the United States was performed.

Results

Seven patients were identified. The median time between initial clipping and diagnosis of recurrence was 13 years (range, 5–20 years). No morbidity or mortality was associated with PED placement. Complete occlusion was achieved in all patients with imaging follow-up. A history of prior clipping did not affect PED placement or outcome.

Conclusions

PED for recurrent aneurysms after clipping may be a feasible alternative to reoperation. In our experience, treatment with PED for these aneurysms is safe and efficacious.

Introduction

Microsurgical clipping achieves complete obliteration in 92% of unruptured aneurysms1, 2 and 84% of ruptured aneurysms.3 Expected and unexpected aneurysm residuals, which occur in 4%–8% of cases, can lead to recurrence.4, 5, 6 Even with complete obliteration, aneurysm recurrence has been documented. It can arise from the location of the initial aneurysm or, more commonly, from the weakened segment of the adjacent artery. The annual recurrence rate of aneurysms completely obliterated after clipping is 0.26% to 0.52%.7, 8 In a recent study by Owen et al.,6 the hemorrhage rate of recurrent aneurysms after clipping was 50%, emphasizing the need for intervention after detection.

Reoperation is usually associated with a higher rate of morbidity and mortality,4 especially with a longer time intervals from initial surgery. In 2011, Pipeline Embolization Device (PED; Covidien–Ev3, Plymouth, Minnesota, USA) was approved for endovascular treatment of large or giant wide-necked intracranial aneurysms,9 with an increasing number of reports on off-label use.10, 11, 12, 13, 14, 15, 16, 17, 18, 19

Section snippets

Methods

Two major academic institutions in the United States contributed data for patients who underwent PED placement for recurrent aneurysms after clipping between 2014 and 2015. Institutional review board approval was obtained at both centers. Radiographic outcome was assessed using digital subtraction angiography. Clinical outcome was recorded as modified Rankin Scale (mRS) at last follow-up.

Results

Seven patients were identified and included in this study (Table 1); all were women with a median age of 49 years (range, 30–70 years). All patients underwent surgical clipping for intracranial aneurysm at an earlier time and developed recurrent aneurysms later. The median time between original surgery and diagnosis of recurrence was 13 years (range, 5–20 years). In 6 cases (85.7%), the recurrence was asymptomatic and found incidentally on follow-up imaging, or imaging done for other unrelated

Discussion

In this series, we report our experience with PED use for recurrent aneurysms after surgical clipping. Among the 7 included patients, only 1 patient (14.3%) presented with a ruptured aneurysm and subarachnoid hemorrhage. However, because of the high rupture rate of recurrent aneurysms related to weak pathologic wall, early treatment was warranted.4, 6 The mean time interval between first surgery and recurrence was 13 years (range, 5–20 years). The long time interval makes reoperation a less

Conclusion

The endovascular treatment of recurrent aneurysm after surgical clipping may provide an interesting alternative for reoperation. Whereas coil embolization for these aneurysms has been reported, limitations regarding aneurysm morphology and recanalization remain. In the present study, we have reported our initial experience with PED in treatment of these aneurysms. Complete occlusion was achieved in all cases with imaging follow-up without any significant morbidity or mortality.

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