Tips and Tricks in Microsurgical Treatment for Previously Embolized Aneurysms-Three-Dimensional Video

One of the most popular treatment strategies for complex cerebral aneurysms with wide necks is stent-assisted coiling.¹ Although it is a minimally invasive technique, it is associated with higher recurrence rates (approximately 20%) compared with surgical clipping.² Recanalization is more common principally in ruptured aneurysms as well as in giant aneurysms, aneurysms located in the posterior circulation, aneurysms with a relatively wide neck morphology, and aneurysms followed for >1 year.^2-6 Tirakotai et al. classified the indications for surgical treatment after coiling into 3 groups: 1) surgery of incompletely coiled aneurysms; 2) surgery for mass effects on neural structures; 3) surgery for vascular complications.⁷ Recanalization, if significant, often requires retreatment. Retreating with additional coils fails in perhaps 50% of cases.³ On the other hand, surgical clipping is complicated and difficult to perform. Recanalized aneurysms are categorized into 3 types: type I, coils are compressed; type II, coils are migrated; type III, coils are migrated, and multiple coils fill its neck or the parent artery. Direct clipping can be applied to types I and II, whereas trapping, wrapping, or auxiliary revascularization is required in type III.² Coil extraction should not be attempted regularly because it is associated with high morbidity.⁸ In this three-dimensional video, we present the microsurgical treatment of a type I recanalized anterior communicating artery aneurysm, which in serial digital subtraction angiography control scans showed residual patency, progressive growth, and changes in its hemodynamic behavior (Video).