Early versus Late Clipping of Partially Coiled Ruptured Intracranial Aneurysms with Minimally Invasive Approaches

Introduction: Endovascular coiling has emerged as the optimal treatment for the majority of ruptured intracranial aneurysms. In certain cases, microsurgical clipping is indicated for definitive treatment following initial partial coiling for dome protection. Theses aneurysms require eventual definitive treatment in the form of microsurgical clipping, which can be done early (during initial hospitalization) or in delayed fashion. In the current endovascular era, the authors have developed their own practice to maximize the utility of tailored minimally invasive open approaches for microsurgical clipping of ruptured aneurysms initially stabilized via conservative endovascular coiling.

Objective: To compare the safety and efficacy of early clipping (EC) versus late clipping (LC) for definitive treatment of partially coiled ruptured aneurysms.

Method: A retrospective analysis was performed of patients who underwent clipping of their ruptured aneurysm after initial partial coiling (Example in [Fig. 1]). Patients were divided based on the time from aneurysmal rupture to clipping as follows: EC (≤30 days) and LC (>30 days). Outcome measures included complications, modified Rankin Scale (mRS) at discharge, and at last follow-up.

Fig. 1

Result: Seventeen patients (EC: 6; LC: 11) underwent partial coiling of the ruptured aneurysm as initial treatment. Mean time from rupture to clipping was 15 days in the EC group, and 275 days in the LC group. There were differences between the groups in proportion of patients with mRS 0–1 at discharge (EC: 100% vs. LC: 63.6%) and mRS 0–1 at follow-up (EC: 100% vs. LC: 81.8%) ([Table 1]). No complications were reported in the EC group. In the LC group, one patient developed postoperative seizures, and one patient an epidural hematoma. There were no aneurysm re-ruptures in either group.

Table 1

Conclusion: Microsurgical clipping of ruptured cerebral aneurysms initially treated by partial coil embolization is safe and effective when performed during the initial hospitalization after the vasospasm period. This strategy combines the improved safety profile of endovascular coiling at presentation, with optimal definitive aneurysm treatment afforded by microsurgical clipping, during the initial hospitalization for select patients. EC may improve outcomes and carry a lower risk of complications when compared to LC.

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Artikel online veröffentlicht:
05. Februar 2024