Neurointervention.  2024 Jul;19(2):92-101. 10.5469/neuroint.2024.00108.

Feasibility, Safety, and Efficacy of Endovascular vs. Surgical Treatment of Unruptured Multi-Sac Intracranial Aneurysms in a Single-Center Retrospective Series

• Goertz L
• Timmer M
• Zopfs D
• Kaya K
• Gietzen C
• Kottlors J
• Pennig L
• Schlamann M
• Goldbrunner R
• Brinker G
• Kabbasch C

• KMID: 2556660
• DOI: http://doi.org/10.5469/neuroint.2024.00108

Abstract

Purpose
Multi-sac aneurysms (MSAs) are not uncommon, but studies on their management are scarce. This study aims to evaluate and compare the feasibility, safety, and efficacy of MSAs treated with either clipping or coiling after interdisciplinary case discussion at our center.
Materials and Methods
We retrospectively analyzed MSAs treated by microsurgical clipping, coiling, or stent-assisted coiling (SAC). Treatment modalities, complications, angiographic results, and clinical outcomes were evaluated. Major neurological events were defined as a safety endpoint and complete occlusion as an efficacy endpoint.
Results
Ninety patients (mean age, 53.2±11.0 years; 73 [81.1%] females) with MSAs met our inclusion criteria (clipping, 50; coiling, 19; SAC, 21). Most aneurysms were located in the middle cerebral artery (48.9%). All clipping procedures were technically successful, but endovascular treatment failed in 1 coiling case, and a switch from coiling to SAC was required in 2 cases. The major event rates were 4.0% after clipping (1 major stroke and 1 intracranial hemorrhage) and 0% after endovascular therapy (P=0.667). At mid-term angiographic follow-up (mean 12.0±8.9 months), all 37 followed clipped aneurysms were completely occluded, compared to 8/17 (41.7%) after coiling and 11/15 (73.3%) after SAC (P<0.001). Coiling was significantly associated with incomplete occlusion in the adjusted analysis (odds ratio, 11.7; 95% confidence interval, 2.7–52.6; P=0.001).
Conclusion
Both endovascular and surgical treatment were feasible and safe for MSAs. As coiling was associated with comparatively high recanalization rates, endovascular treatment may be preferred with stent support.

Keyword

Aneurysm; Surgery; Catheter

Figure

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  Fig. 1. Three-dimensional reconstructions from rotational angiography showing illustrative aneurysms with regular margin (A), irregular margin (B), daughter sac (C), and lobulation (D).

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  Fig. 2. Digital subtraction angiography (A) and three-dimensional reconstruction from rotational angiography (B) show an unruptured aneurysm at the bifurcation of the middle cerebral artery with a daughter sac. The aneurysm neck is wide and covers the proximal part of the inferior M2 stem. Based on patient preference, the aneurysm was targeted for coiling. During insertion of the framing coil (C), the lower part of the coil protruded into the inferior M2 trunk (arrow) (D), resulting in flow reduction within the vessel. Therefore, the coil was removed. Although stent-assisted coiling was potentially an alternative endovascular option after antiplatelet loading, we assumed an increased risk of periprocedural complications with and the patient underwent microsurgical clipping.

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  Fig. 3. Stand-alone coiling. (A, B) A patient in thier 20s with a wide-necked bilobulated aneurysm at the terminal internal carotid artery. (C) The aneurysm sacs were embolized consecutively with 4 coils until complete occlusion was achieved. (D) After 3 months, the aneurysm showed recanalization due to coil compaction. (E) After retreatment with a combination of Woven EndoBridgeTM (MicroVention) (not visible behind the coils) and recoiling (4 coils), the aneurysm showed stable occlusion at long-term follow-up.

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  Fig. 4. Microsurgical clipping. (A, B) A patient in thier 40s presented with acute third cranial nerve palsy. Three-dimensional DSA showed a trilobulated aneurysm at the posterior communicating artery (Pcom). The aneurysm was clipped via the pterional approach and punctured to release the mass effect. Stenosis of the parent artery was ruled out by intraoperative micro-doppler ultrasound and indocyanine green videoangiography. (C) At 3-month follow-up, the aneurysm was completely excluded from circulation and the Pcom was patent. The oculomotor nerve palsy was fully recovered. ICA, internal carotid artery.

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