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Long-term follow-up of ruptured intracranial aneurysms treated by microsurgical wrapping with autologous muscle

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Abstract

The purpose of this study is to describe our series of nine unclippable and uncoilable ruptured aneurysms in eight patients treated by microsurgical wrapping with autologous muscle. Records were retrospectively reviewed for rebleeding rate, morbidity and mortality, changes in size or the aneurysm’s configurations, and inflammatory reaction. We conducted a Medline search in the post-microsurgical era, excluding patients in whom wrapping was part of the aneurysm treatment in combination with clipping or coiling. The surgically related morbidity was 12.5 %. Global mortality rate was 25 % due to vasospasm (one case) and rebleeding (one case). Six patients are still alive. Rebleeding rate was 14.3 % within 6 months; then, it was zero. Glasgow outcome scale (GOS) score at discharge was 1 and 4 in one patient, respectively, and 5 in the remaining six. Mean clinical follow-up was 126 months. GOS at last follow-up was 4 and 5 in 50 % of patients, respectively. Mean mRS score was 0.8 at 2 months, and 2.4 at 12 months. Follow-up MR demonstrated persistence of the aneurysm’s sac, without changes in size and configuration. Patients did not describe or exhibit symptoms attributable to complications inherent to the use of muscle. Microsurgical muscle-wrapping of ruptured intracranial aneurysm is safe, is associated with a low rate of acute and delayed postoperative complications and rebleeding, and could be a valid alternative for unclippable and non-amenable to endovascular procedure ruptured aneurysms.

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Authors and Affiliations

  1. Neurosurgical Clinic, Department of Neurosciences, Psychiatry and Anaesthesiology, University of Messina Medical School, A.O.U. Policlinico G. Martino, Via Consolare Valeria, 1, 98125, Messina, Italy

    Antonino Germanò, Stefano Priola, Filippo Flavio Angileri, Alfredo Conti, Domenico La Torre, Salvatore Cardali, Giovanni Raffa, Lucia Merlo & Francesco Tomasello

  2. Neuroradiology, Department of Radiology, University of Messina Medical School, Messina, Italy

    Francesca Granata & Marcello Longo

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  1. Antonino Germanò
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Comments

Richard A. Lochhead, Phoenix, USA

Germanò et al. review their series of ruptured aneurysms treated by microsurgical wrapping with autologous muscle. This series reviews 730 treated aneurysms and found eight patients with nine ruptured aneurysms that were microsurgically wrapped with autologous muscle because they were not amenable to microsurgical clipping or endovascular coil occlusion. The mean clinical follow-up was 126 months. Two patients died, one from vasospasm and one from a rebleed 6 months after wrapping. Three of the remaining six patients had follow-up MRI/MRA which demonstrated stable aneurysm size.

The wrapping of aneurysms with muscle was first described in 1930 but nearly all the reports on this technique have been published before the use of operating microscopes and other technological advancements for aneurysm treatment. Modern microsurgical and endovascular techniques are now able to treat nearly all aneurysms. Therefore, the natural history and treatment challenges of modern aneurysms which require wrapping are likely very different from those aneurysms treated in the pre-microsurgical era.

At our institution, we would typically clip-wrap with GorTex and then follow-up 1–2 weeks later with an endovascular stent to strengthen the artery wall. This article presents an alternative treatment for these challenging lesions. It is still not clear which of the many techniques are best but this article does demonstrate that microsurgical wrapping with autologous muscle is an option when other traditional measures will not work. The authors should be commended for their work.

Michael T. Lawton, San Francisco, USA

In this article, nine unclippable/uncoilable ruptured aneurysms in eight patients were microsurgically wrapped with autologous muscle safely and with a low rate of rebleeding: 14.3 % in the first 6 months and 0 % in the ensuing decade. Although the acute rebleeding rate may seem low, it is significantly greater than that conferred by other treatment techniques like clipping, trapping with or without bypass, or coiling. Therefore, wrapping should be considered as a treatment of last resort when these other modalities fail. It is more applicable to anterior circulation aneurysms than posterior circulation aneurysms that are less accessible. As the authors discuss, the mechanism of protection is probably a reinforcement of the aneurysm wall by inflammation and scar tissue over time. The extra layer of muscle likely provides little mechanical protection. Therefore, wrapped aneurysms must be considered unsecured during the postoperative period during which vasospasm may need to be treated, which may contraindicate conventional therapies like hypertensive therapy. In my practice, I prefer a more aggressive approach with ruptured aneurysms that definitively excludes the aneurysm, and I have resorted to complex clip reconstructions or bypasses when the anatomy is unfavorable for simple clipping. For whatever reason, wrapping always feels, to some degree, like a surgical failure, but I think it is more acceptable with unruptured aneurysms where there is no rebleeding risk. To date, no data inform us whether muscle, muslin, or some other material is best. This article reminds us that temporalis muscle is a ready wrapper when needed.

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Germanò, A., Priola, S., Angileri, F.F. et al. Long-term follow-up of ruptured intracranial aneurysms treated by microsurgical wrapping with autologous muscle. Neurosurg Rev 36, 123–132 (2013). https://doi.org/10.1007/s10143-012-0408-z

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