• Christoph J Griessenauer, Philippe Dodier, Nico H Stroh, Petra A Mercea, Gerhard Bavinzski, Christian Dorfer, Karl Rössler, Andreas Gruber, Matthias Gmeiner, Claudius Thomé, Klaus A Leber, Stefan Wolfsberger, Mustafa Baghban, Rahman Al-Schameri, Michael Kral, Som Thakur, Manuel Lunzer, Branko Popadic, Camillo Sherif, Vilém Juráň, Martin Smrčka, David Netuka, Anna Štekláčová, Radim Lipina, Tomáš Hrbáč, Zdeněk Večeřa, Jiří Fiedler, Marek Grubhoffer, Lumír Hrabálek, David Krahulík, Lukas Koller, Thomas Kretschmer, Vladimír Přibáň, Jan Mraček, Martin Sameš, Aleš Hejčl, Jan Klener, Jan Šroubek, and Ondra Petr.
• Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.
• Neurosurgery. 2024 Jun 12.

Background And ObjectivesEndovascular treatment of cerebral aneurysms has tremendously advanced over the past decades. Nevertheless, aneurysm residual and recurrence remain challenges after embolization. The objective of this study was to elucidate the portion of embolized aneurysms requiring open surgery and evaluate whether newer endovascular treatments have changed the need for open surgery after failed embolization.MethodsAll 15 cerebrovascular centers in Austria and the Czech Republic provided overall aneurysm treatment frequency data and retrospectively reviewed consecutive cerebral aneurysms treated with open surgical treatment after failure of embolization from 2000 to 2022. All endovascular modalities were included.ResultsOn average, 1362 aneurysms were treated annually in the 2 countries. The incidence increased from 0.006% in 2005 to 0.008% in 2020 in the overall population. Open surgery after failed endovascular intervention was necessary in 128 aneurysms (0.8%), a proportion that remained constant over time. Subarachnoid hemorrhage was the initial presentation in 70.3% of aneurysms. The most common location was the anterior communicating artery region (40.6%), followed by the middle cerebral artery (25.0%). The median diameter was 6 mm (2-32). Initial endovascular treatment included coiling (107 aneurysms), balloon-assist (10), stent-assist (4), intrasaccular device (3), flow diversion (2), and others (2). Complete occlusion after initial embolization was recorded in 40.6%. Seventy-one percent of aneurysms were operated within 3 years after embolization. In 7%, the indication for surgery was (re-)rupture and, in 88.3%, reperfusion. Device removal was performed in 16.4%. Symptomatic intraoperative and postoperative complications occurred in 10.2%. Complete aneurysm occlusion after open surgery was achieved in 94%.ConclusionOpen surgery remains a rare indication for cerebral aneurysms after failed endovascular embolization even in the age of novel endovascular technology, such as flow diverters and intrasaccular devices. Regardless, it is mostly performed for ruptured aneurysms initially treated with primary coiling that are in the anterior circulation.Copyright © Congress of Neurological Surgeons 2024. All rights reserved.

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