With the introduction of Guglielmi detachable coils (GDC), endovascular treatment of intracranial aneurysms is rapidly gaining popularity as an alternative approach to surgical clipping, especially for unruptured aneurysms. In our institute, priority has been given to endovascular treatment for unruptured aneurysms since 1995. However, 18 patients were referred to direct surgical treatment because of difficulty in endovascular treatment or complications during the procedure. In this study, we analyze characteristics of these aneurysms and discuss surgical problems. The locations of aneurysms were the middle cerebral artery in 10, the anterior communicating artery in 5 and the internal carotid artery in 3. The reasons of referral from endovascular surgery were broad neck aneurysms in 10, too small size in 4, fusiform shape in 3 and complications during procedures in 3. Surgical methods were simple neck clipping in only 6, while a combination of neck clipping and wrapping was employed in 9 and multiple clipping reconstructing the parent artery in 3. The postoperative course was uneventful except for two cases-one had delayed arterial occlusion probably due to angitis by the wrapping material, the other had bleeding from the aneurysm after multiple clipping reconstructing the parent artery and wrapping. All direct surgeries after complications of endovascular treatment were done for aneurysms of the anterior communicating artery. Bleeding by endovascular procedure occurred in 2, and anterior cerebral arterial occlusion in 1. The bleeding point was the side wall of the aneurysm in 1 case. Recanalization of the occluded artery was difficult even after direct embolectomy.
In conclusion, it was also difficult to obtain satisfactory results with direct surgery for unruptured aneurysms, which were referred from endovascular surgery because of difficulty or complications. These cases had to be managed more carefully to minimize complications.
