Literature Review

Neck remnants and the risk of aneurysm rupture after endovascular treatment with coiling or stent-assisted coiling: much ado about nothing?


Neck or aneurysm remnant after endovascular treatment is a common criticized issue when surgical clipping is compared. The investigators did a multi-center retrospective chart review of 1292 aneurysms treated with endovascular coiling/stent assisted coiling to assess the risk of subsequent rupture when neck/dome remnants are present after treatment. The degree of occlusion was evaluated by cerebral angiography which was stratified according to the Raymond–Roy Occlusion Classification (RROC). Only 626 RROC II or III aneurysms were included in the study. Most of the aneurysms evaluated were located in the anterior circulation. About two-third of the patients underwent primary coiling. There was no post-treatment rupture in patients treated with stent assisted coiling. However, due to a low number of this population, the treatment type had only a marginal impact on post-treatment rupture. Thirteen (2.1%) of the 626 aneurysms ruptured during mean 7.3 mo follow-up period. Rupture at the time of presentation, size of the aneurysm, and increasing age were significant predictors of a post-treatment rupture.        

This study showed rupture at presentation was a statistically significant predictor of a post-treatment rupture. Therefore, aggressive treatment of ruptured aneurysms to achieve complete occlusion as much as possible at beginning was suggested. On the contrary, the natural history of residual neck/aneurysm remnant of unruptured aneurysms was quite benign. Risks from treatment aggressiveness may outweigh the natural history.