Results of surgical clipping in a neurointerventional dominant department.

OBJECTIVES

It has been 10 years since the publication of International Subarachnoid Aneurysm Trial (ISAT) (1-3) and the first-line treatment for cerebral aneurysms in many UK neurosurgical centres is endovascular occlusion. Local audit has shown a significant reduction in surgical clipping cases since 2002, with a fall from over 150 cases per year pre ISAT, to approximately 25 cases per year currently. More so the cases referred for surgical occlusion represent more challenging lesions. With such a reduction in surgical numbers we felt it prudent to review our recent surgical outcomes.

DESIGN

Retrospective analysis of prospectively collected data.

SUBJECTS

47 patients (32 females, 15 males), mean age: 53 (range, 29-74) years underwent surgical clipping of cerebral aneurysms from January 2012 to September 2013.

METHODS

Case notes, neuroradiology reports and cerebral angiograms were reviewed. Patient outcome was stratified according to Glasgow Outcome Score; 4-5 good outcome and 1-3 poor outcome.

RESULTS

Of the aneurysms clipped, 40 patients had suffered a subarachnoid haemorrhage and 7 were treated for unruptured aneurysms. The reasons for referral for surgical clipping were the presence of an aneurysmal clot 9 (19%), 'failed coiling' 16 (34%) and unsuitability for endovascular intervention due to anatomical considerations 22 (47%). A good outcome was recorded in 20/22 (91%) of patients who underwent clipping for anatomical reasons, 11/16 (69%) of patients who failed endovascular treatment and 5/9 (56%) of patients with an aneurysmal clot (p = 0.05). Of 31 aneurysms with post clipping angiographic studies, 28 (90%) had complete or satisfactory aneurysm obliteration.

CONCLUSIONS

In the current era of neurointerventional dominance, the case mix undergoing microsurgical clipping is more challenging than the pre-ISAT cohort; however, post-procedural angiography has demonstrated a relatively high obliteration rate. It is reassuring that good neurological outcomes were observed in patients clipped for anatomical reasons.