ANEURYSM CLIPPING AFTER ENDOVASCULAR TREATMENT WITH COILS - A REPORT OF 8 PATIENTS

BETWEEN JANUARY 1990 and December 1994, patients with subarachnoid hem orrhage related to ruptured aneurysms who were referred to our institu tion were treated by neurosurgical and neuroradiological teams. In eac h patient, the respective indications for neurosurgical or endovascula r treatment were discussed, taking into consideration patients' age an d the morphological and topographical aneurysm features. We report eig ht cases of patients with subarachnoid hemorrhage who underwent operat ions after primary endovascular procedures (Hunt and Hess scores III, IV, and V). The indications for surgical treatment were as follows. Fi rst, deliberate partial occlusion of the aneurysm (two aneurysms of th e internal carotid artery and one aneurysm of the anterior communicati ng artery) was performed to obtain only partial clotting of the aneury sm sac by free coils. However, this procedure was discontinued in favo r of the use of Guglielmi detachable coils. The second indication was partial occlusion after an endovascular procedure (two aneurysms of th e middle cerebral artery and one internal carotid artery aneurysm). Th e third indication was re-expansion of the aneurysm 1 year after the e ndovascular treatment (one middle cerebral artery aneurysm). The final indication was secondary rupture of the aneurysm sac and false aneury sm around the migrating coil (one aneurysm of the pericallosal artery) . During surgery, the aneurysm sac appeared translucent. The coils bul ged out and stretched the aneurysm sac. One ruptured the membrane lead ing to a subarachnoid hemorrhage during the endovascular procedure. No hemorrhage occurred during the surgical clipping. Aneurysm obliterati on was easily performed, especially when the packing was partial, but was very difficult when the complete aneurysm closure led to a stenosi s of the parent vessel. A giant sylvian aneurysm rest, visible only wi th angiography, was left untreated. This series illustrates an origina l experience, which led us to conclude that aneurysm surgery with coil s in place is not as difficult as is often thought.