title: Microsurgery for previously coiled aneurysms: experience with 81 patients.
abstract: BACKGROUND
  Residual and recurrent intracranial aneurysms after endovascular treatment with Guglielmi detachable coils may necessitate a microsurgical occlusion.
  
  
  OBJECTIVE
  To analyze the microsurgical technique and describe how the location, morphology, and appearance of the coiled aneurysm affect the technique.
  
  
  METHODS
  We retrospectively analyzed 81 patients with 82 previously coiled aneurysms treated microsurgically at 2 Finnish neurosurgical university hospitals in Helsinki and Kuopio between July 1995 and August 2009. Seven videos were selected to demonstrate the microsurgical strategy in various locations.
  
  
  RESULTS
  Fifty-eight aneurysms (71%) were located at anterior circulation and 24 (29%) at posterior circulation. Fifteen patients were operated on within the first month (early surgery) after coiling, whereas 66 were treated later (late surgery). Complete or partial removal of coils during surgery may facilitate clipping, but is significantly (P < .001) more difficult to accomplish in late surgery. Removal of coils may also increase the chance of poor outcome. Chance of poor outcome also increased with intraoperative aneurysm rupture, size of the aneurysm, and posterior circulation location. Good clinical outcome (same or better clinical condition 3 months after surgery) was achieved in 71 patients (88%). After microsurgery, 4 patients were severely disabled and 6 patients died, 3 of them because of poor clinical condition.
  
  
  CONCLUSIONS
  Complete microsurgical occlusion of the residual aneurysm is possible. However, in large or giant aneurysms direct microsurgery is a challenging high-risk procedure, and we recommend that these patients be referred to a dedicated neurovascular center to minimize surgical complications. Even in experienced hands, use of different bypass procedures may be the best option for demanding growing lesions, especially those in the posterior circulation.
authors.affiliation: Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland. rossana.romani@hus.fi
authors.forename: Rossana
authors.initials: R
authors.lastname: Romani
authors.forename: Hanna
authors.initials: H
authors.lastname: Lehto
authors.forename: Aki
authors.initials: A
authors.lastname: Laakso
authors.forename: Angel
authors.initials: A
authors.lastname: Horcajadas
authors.forename: Riku
authors.initials: R
authors.lastname: Kivisaari
authors.forename: Mikael
authors.initials: M
authors.lastname: von und zu Fraunberg
authors.forename: Mika
authors.initials: M
authors.lastname: Niemelä
authors.forename: Jaakko
authors.initials: J
authors.lastname: Rinne
authors.forename: Juha
authors.initials: J
authors.lastname: Hernesniemi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D004621:Embolization, Therapeutic / Q000379:methods; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods; D012086:Reoperation; D012189:Retrospective Studies; D055815:Young Adult