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Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 676-677

Clipping of a re-grown basilar bifurcation aneurysm following coiling: An extreme surgical challenge


Department of Neurosurgery, Room No: 7, 6th Floor, Neurosciences Centre, All India, Institute of Medical Sciences, New Delhi 110 029, India

Date of Submission06-Oct-2012
Date of Decision17-Oct-2012
Date of Acceptance18-Nov-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Sarat P Chandra
Department of Neurosurgery, Room No: 7, 6th Floor, Neurosciences Centre, All India, Institute of Medical Sciences, New Delhi 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.105223

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How to cite this article:
Chandra SP, Kumar A. Clipping of a re-grown basilar bifurcation aneurysm following coiling: An extreme surgical challenge. Neurol India 2012;60:676-7

How to cite this URL:
Chandra SP, Kumar A. Clipping of a re-grown basilar bifurcation aneurysm following coiling: An extreme surgical challenge. Neurol India [serial online] 2012 [cited 2019 Aug 17];60:676-7. Available from: http://www.neurologyindia.com/text.asp?2012/60/6/676/105223


Sir,

Endovascular treatment has been accepted as one of the options for treating aneurysms. [1] However, the risks with this procedure include re-rupture [2] or re-growth of aneurysm. [3] Treating these complications is challenging by both endovascular [4] and surgical [4],[5],[6],[7] techniques. We report clipping in a case of basilar bifurcation aneurysm (BBA), coiled adequately, presenting with re-growth and rupture 6 years after the initial procedure.

A 44-year-old male presented to emergency with Hunt and Hess grade II subarachnoid haemorrhage (SAH). Digital subtraction angiography (DSA) revealed a large BBA [Figure 1]. Patient underwent endovascular coiling and complete occlusion of aneurysm. Patient was discharged in a satisfactory condition. Follow-up DSA after 3 months revealed complete occlusion of aneurysm [Figure 2]a. Patient was then lost to follow-up and presented 6 years later with grade IV SAH (GCS-5/15). Repeat DSA revealed re-grown BBA with wide neck (9.5 mm), large dome (12.4 ΄ 11.1 mm) that incorporated bilateral posterior cerebral artery (PCA) origins [Figure 2]b and impacted coil mass in superior and lateral aspect of fundus [Figure 2]b. A decision to clip the aneurysm was taken keeping in mind the wide neck of aneurysm and financial status of the patient.
Figure 1: Angiogram of the patient prior to embolization. (a) Lateral view, (b) AP view

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Figure 2: Immediate post‑coiling angiogram, showing adequate occlusion of BBA (a) Large recurrence (b) seen 6 years later, when the patient presented with Grade II SAH. It is seen that BBA has a broad base. The coils could be seen through the dome due to its erosion by the coils (c), (d) shows final configuration of clip application. The proximal clip was used to crush and cut coils thus allowing the distal clip to be applied over the neck (downward arrow), allowing complete obliteration of aneurysm (e)

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Patient underwent right fronto-temporo-orbito-zygomatic craniotomy and subtemporal approach was used. An anteriorly and superiorly directed BBA [Figure 2]c partially obstructed with coils and with a thin dome [Figure 2]c was visualized. A temporary clip was applied over the basilar trunk just proximal to aneurysm [Figure 2]c. Following this, a straight clip application was attempted over the neck. This however, resulted in rupture at the dome. Using suction to clear blood, clipping was again attempted. However, this resulted in the clip slipping proximally to occlude bilateral PCAs. Following this, dome was opened, and coils cut with scissors. The resulting reduction in volume of coils allowed the clip to be applied directly over the coils, thereby crushing them, thus facilitating application of another clip proximally. The coils could not be removed as they were stuck to the sac. This maneuver allowed the second clip to stay in place without slipping proximally over to PCAs [Figure 2]d. The temporary clip over basilar trunk was removed. Temporary clipping time was for six minutes. We did not have any special coil cutting scissors; hence we used routine micro scissors, which got damaged during the procedure making it unusable. Patient was electively ventilated and gradually weaned off from ventilator. Patient slowly improved and at discharge he was conscious, alert though not fully oriented and had no focal deficits. DSA at 3 months revealed a well-clipped aneurysm [Figure 2]e. Follow-up after 2 years revealed the patient to be functionally independent for most of his activities.

There has been progressive increase in the number of patients with aneurysms undergoing coiling since 1991. [8],[9] However, one of the risks of coiling is re-growth. [6] Such a re-growth, poses a surgical challenge when the patient presents late. Coils not only become compact, immobile and incorporated within thrombus, they also cause degeneration of aneurysm wall (the coil acid phenomenon). [8] This increases the risk of rupture as happened in our patient. Extraction of coils from aneurysm sac may be attempted. However, in cases who present late, this may be difficult [10] and dangerous. [9] Clipping of aneurysm without extraction of coils may not be possible if coils are present at base/neck or are incorporated into parent vessel. [9] In such a case, coils may be cut with micro scissors or stronger scissors (kopitnik), thereby reducing the volume and creating space for clipping. We did try to remove coil, but could not do so due to its adherence with sac. The cutting and crushing of coils was performed to facilitate clip application. Though there is a theoretical risk of distal embolization of coil fragments, it did not happen in our case. In the published literature, 15-30% of the aneurysms requiring surgery post-coiling, coiling was done in the posterior circulation. [4],[7],[11] However very few cases of post-coiling recurrent BBA treated surgically have been reported. [3],[6],[7],[10],[11]

In our case, post-coiling re-grown BBA presented after a long interval of 6 years with rupture. Our case highlights the fact that aneurysms may present with re-growth even after such a long interval following coiling, thereby stressing the need of long term follow-up. The reducing experience of surgeons due to wider usage of coiling coupled with re-growth of aneurysm being more difficult for clipping may present a "clear and present danger" for future generations in managing these cases. Improvement in endovascular technology hopefully should fill up these gaps, but till then, role of surgery cannot be completely excluded.

 
  References Top

1.Cowan JA, Jr., Ziewacz J, Dimick JB, Upchurch GR Jr., Thompson BG. Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms. J Neurosurg 2007;107:530-5.  Back to cited text no. 1
    
2.Grunwald IQ, Papanagiotou P, Struffert T, Politi M, Krick C, Gül G, et al. Recanalization after endovascular treatment of intracerebral aneurysms. Neuroradiology 2007;49:41-7.  Back to cited text no. 2
    
3.Mericle RA, Wakhloo AK, Lopes DK, Lanzino G, Guterman LR, Hopkins LN. Delayed aneurysm regrowth and recanalization after Guglielmi detachable coil treatment-case report. J Neurosurg 1998;89:142-5.  Back to cited text no. 3
    
4.Lejeune JP, Thines L, Taschner C, Bourgeois P, Henon H, Leclerc X. Neurosurgical treatment for aneurysm remnants or recurrences after coil occlusion. Neurosurgery 2008;63:684-91.  Back to cited text no. 4
    
5.Veznedaroglu E, Benitez RP, Rosenwasser RH. Surgically treated aneurysms previously coiled: Lessons learned. Neurosurgery 2004;54:300-3.  Back to cited text no. 5
    
6.Waldron JS, Halbach VV, Lawton MT. Microsurgical management of incompletely coiled and recurrent aneurysms: Trends, techniques, and observations on coil extrusion. Neurosurgery 2009;64:301-15.  Back to cited text no. 6
    
7.Romani R, Lehto H, Laakso A, Horcajadas A, Kivisaari R, von und zu Fraunberg M, et al. Microsurgery for previously coiled aneurysms: Experience with 81 patients. Neurosurgery 2011;68:140-53.  Back to cited text no. 7
    
8.Guglielmi G, Vinuela F, Sepetka I, Macellari V. Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: Electrochemical basis, technique, and experimental results. J Neurosurg 1991;75:1-7.  Back to cited text no. 8
    
9.Gurian JH, Martin NA, King WA, Duckwiler GR, Guglielmi G, Vinuela F. Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization. J Neurosurg 1995;83:843-53.  Back to cited text no. 9
    
10.Dorfer C, Gruber A, Standhardt H, Bavinzski G, Knosp E. Management of residual and recurrent aneurysms after initial endovascular treatment. Neurosurgery 2012;70:537-53.  Back to cited text no. 10
    
11.Yasui T, Komiyama M, Iwai Y, Yamanaka K, Matsusaka Y, Morikawa T, et al. Regrowth and fatal rerupture despite proximal occlusion after coil embolization of a ruptured large basilar bifurcation aneurysm-case report. Neurol Med Chir 2004;44:587-90.  Back to cited text no. 11
    


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