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23.06.2017 | Original Article - Vascular | Ausgabe 9/2017

Acta Neurochirurgica 9/2017

Early retreatment after surgical clipping of ruptured intracranial aneurysms

Zeitschrift:
Acta Neurochirurgica > Ausgabe 9/2017
Autoren:
Yoshiro Ito, Tetsuya Yamamoto, Go Ikeda, Wataro Tsuruta, Kazuya Uemura, Yoji Komatsu, Akira Matsumura
Wichtige Hinweise

Comments

This interesting report shows that despite the introduction of fluorescence microangiography using ICG and microDoppler, complete aneurysm exclusion remains a challenge and in particular in the complex anatomy of the anterior communication artery. It emphasizes the need for an intraoperative assessment of the treatment quality and multidisciplinary collaboration. Although the risk of rebleeding and further degradation of the neurological condition of the patients is very low, the community should persevere, improving the case selection for each different treatment modality or combination thereof and further developing new techniques. In the light of such low failure rates, multicenter collaborations are mandatory to be able to demonstrate statistically significant progresses quickly.
Philippe Bijlenga
Geneva, Switzerland

Abstract

Background

Although a rerupture after surgical clipping of ruptured intracranial aneurysms is rare, it is associated with high morbidity and mortality. The causes for retreatment and rupture after surgical clipping are not clearly defined.

Methods

From a prospectively maintained database of 244 patients who had undergone surgical clipping of ruptured intracranial aneurysms, we selected patients who experienced retreatment or rerupture within 30 days after surgical clipping. Aneurysm occlusions were examined by microvascular Doppler ultrasonography and indocyanine green video-angiography. Indications for retreatment included rerupture and partial occlusion. We analyzed the characteristics and causes of early retreatment.

Results

Six patients (2.5%, 95% CI 0.9 to 5.3%) were retreated within 30 days after surgical clipping, including two patients (0.8%, 95% CI 0.1 to 2.9%) who experienced a rerupture. The retreated aneurysms were found in the anterior communicating artery (AcomA) (n = 5) and basilar artery (n = 1). Retreatment of the AcomA (7.5%) was performed significantly more frequently than that of other arteries (0.56%) (p < 0.01). A laterally projected AcomA aneurysm (17.4%) was more frequently retreated than were other aneurysm types (2.3%). Cases of laterally projecting AcomA aneurysms tended to result from an incomplete clip placed using a pterional approach from the opposite side of the aneurysm projection.

Conclusions

Despite developments, the rates of retreatment and rerupture after surgical clipping remain similar to those reported previously. Retreatment of the AcomA was significantly more frequent than was retreatment of other arteries. Patients underwent retreatment more frequently when they were originally treated for lateral type aneurysms using a pterional approach from the opposite side of the aneurysm projection. The treatment method and evaluation modalities should be considered carefully for AcomA aneurysms in particular.

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