Technical Note
Endovascular treatment of recurrent intracranial aneurysms following previous microsurgical clipping with the Pipeline Embolization Device

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Abstract

The treatment of intracranial aneurysms with microsurgical clipping is associated with a very low rate of recurrence. However, in cases of aneurysm recurrence after previous clipping, microsurgical dissection due to adhesions and fibrosis may be challenging, and it may be difficult to safely occlude the recurrent lesion without the risk of significant morbidity. Flow-diverting stents have drastically changed the landscape of endovascular neurosurgery. We present two patients with large, recurrent supraclinoid internal carotid artery (ICA) aneurysms which were previously clipped 17 and 23 years ago at outside institutions. Both recurrent lesions were treated with the Pipeline Embolization Device (PED; ev3 Endovascular, Irvine, CA, USA) without radiographic or clinical complications. In the first patient, the 15 mm aneurysm significantly decreased in size at 6 month angiographic follow-up. The 21 mm aneurysm in the second patient was completely occluded 7 months following PED treatment. The moderate degree of in-stent stenosis present on initial follow-up imaging resolved on angiography 11 months post-treatment. The management of recurrent aneurysms after clipping is sparsely reported in the literature due to its infrequent occurrence. In carefully selected cases, flow-diverting stents may be used for complex aneurysms of the distal ICA, even for those which have recurred following microsurgical clipping.

Introduction

Microsurgical clipping has frequently been touted as the “definitive” treatment for intracranial aneurysms. However, aneurysm recurrence after clipping occurs in approximately 1–2% of patients [1], [2], [3], [4], [5]. These recurrent lesions can be managed by repeat microsurgical intervention or by endovascular occlusion [5], [6], [7]. Repeat surgery may be particularly difficult due to associated adhesions and fibrosis. Additionally, clip removal or movement at long-term follow-up may cause significant blood vessel injury [4], [7]. In recent years flow-diverting stents (FDS) such as the SILK stent (Balt Extrusion, Montmorency, France) and Pipeline Embolization Device (PED, ev3 Endovascular, Irvine, CA, USA), have become increasing popular for the treatment of intracranial aneurysms with morphologies not amenable to traditional endovascular approaches. While the efficacy of PED for previously coiled aneurysms has been described, the role of PED for the treatment of previously clipped aneurysms is currently unknown [8], [9]. We present two patients with large, recurrent supraclinoid internal carotid artery (ICA) aneurysms which previously underwent microsurgical clipping. Both recurrent lesions were treated with the PED. We also discuss the role of FDS in the treatment of recurrent intracranial aneurysms following incomplete microsurgical clipping.

Section snippets

Patient 1

A 63-year-old woman presented 4 months after being hospitalized for subarachnoid hemorrhage (SAH) secondary to rupture of a recurrent left supraclinoid ICA aneurysm. The aneurysm had been clipped 17 years previously. The ruptured recurrence was treated at an outside institution with balloon-assisted coil embolization at the time of SAH. At presentation to our center, the patient had mild residual left-sided weakness grade 4 out of 5 which had been present since her initial clipping procedure. The

Discussion

Despite being a more durable treatment for intracranial aneurysms than endovascular coiling, microsurgical clipping does not always result in permanent aneurysm obliteration. In the Cerebral Aneurysm Rerupture After Treatment (CARAT) study which included 711 patients who underwent clipping, the retreatment rate for recurrence was 1.7% [2]. A follow-up analysis of the same study identified degree of aneurysm occlusion to be inversely correlated with the risk of rerupture after initial treatment (

Conclusions

This case series emphasizes the importance of close angiographic surveillance after aneurysm treatment, even in patients who have undergone microsurgical clipping. We present two unique cases in which FDS were used for endovascular reconstruction of complex supraclinoid ICA aneurysms which recurred after clipping. Evaluation of the collateral vascular supply of the branch arteries covered by a FDS is crucial to minimizing clinical sequelae of unintentional occlusion.

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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