Patient Selection

Endovascular treatment of cerebral aneurysms is increasing in part because of the better outcomes for aneurysms that are being managed more commonly using endovascular techniques. The positive short-term outcomes of endovascular therapy have been well established. However, with the increasing population of patients being treated with endovascular management, especially coiling, and longer duration of follow-up, the long-term drawbacks have evolved. ^{1,​ 2,​ 3} These include an important number of recurrences and residuals, coil compaction and extrusion, and occurrence of subarachnoid hemorrhage (SAH) despite initial endovascular treatment. With the growing number of recurrent aneurysms, the need for retreatment is expanding. Treatment of these recurrences and remnants can be challenging, but a multitude of surgical and endovascular techniques are available. The main surgical treatment options include direct microsurgical clipping, aneurysm wrapping, or extracranial–intracranial bypass with parent vessel occlusion ( ▶ Fig. 20.1, ▶ Fig. 20.2, ▶ Fig. 20.3, ▶ Fig. 20.4, ▶ Fig. 20.5). Endovascular treatment methods include recoiling, stenting, stent-assisted coiling, or the use of flow diversion devices such as the pipeline embolization device. Although treatment with recoiling is usually attempted, up to 50% of cases may still require further treatment. ⁴ Furthermore, some recurrences and remnants cannot be managed with a second endovascular intervention because of complex anatomy or difficult endovascular access. Surgical clipping of intracranial aneurysms results in higher rates of complete obliteration as compared to endovascular coiling. However, clipping of previously endovascularly treated aneurysms is more technically challenging than surgical clipping of naïve aneurysms and has its own difficulties attributed to the previously placed coils or stents. However, with appropriate patient selection, the efficacy of the procedure is high and procedural risks are low. The decision to treat recurrent, previously endovascularly treated cerebral aneurysms with microsurgical clipping depends on patient and aneurysm characteristics. Important factors to weigh in during the patient selection process include the following: age less than 70 years; no significant comorbidities or well-controlled comorbidities; patient unreliable to return for follow-up imaging when a recurrence is diagnosed; no prior and current history of smoking; presentation with SAH from the recurrence or residual; patient preference for surgical intervention; wide aneurysm neck; a dome-to-neck ratio of less than 2:1; aneurysm location, with recurrences arising from the anterior communicating artery, the posterior communicating artery, and the middle cerebral artery being the best surgical candidates; aneurysm neck/base incorporating adjacent branching arteries; aneurysms that are less densely packed with coils leaving enough space for clip placement at the neck; and presence of a significant recurrence/residual following the endovascular intervention (>40%) or progression during follow-up occlusion ( ▶ Fig. 20.1, ▶ Fig. 20.2, ▶ Fig. 20.3, ▶ Fig. 20.4, ▶ Fig. 20.5). Microsurgical clipping can be performed after one failed endovascular intervention or multiple interventions. Older patients with several comorbidities, aneurysms in the posterior circulation, unfavorable dome-to-neck ratio, and coils densely packed in the aneurysm neck are less likely to be candidates for surgical clipping.

20.2 Preoperative Preparation

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