Skip to main content


Log in

Early retreatment after surgical clipping of ruptured intracranial aneurysms

  • Original Article - Vascular
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript



Although a rerupture after surgical clipping of ruptured intracranial aneurysms is rare, it is associated with high morbidity and mortality. The causes for retreatment and rupture after surgical clipping are not clearly defined.


From a prospectively maintained database of 244 patients who had undergone surgical clipping of ruptured intracranial aneurysms, we selected patients who experienced retreatment or rerupture within 30 days after surgical clipping. Aneurysm occlusions were examined by microvascular Doppler ultrasonography and indocyanine green video-angiography. Indications for retreatment included rerupture and partial occlusion. We analyzed the characteristics and causes of early retreatment.


Six patients (2.5%, 95% CI 0.9 to 5.3%) were retreated within 30 days after surgical clipping, including two patients (0.8%, 95% CI 0.1 to 2.9%) who experienced a rerupture. The retreated aneurysms were found in the anterior communicating artery (AcomA) (n = 5) and basilar artery (n = 1). Retreatment of the AcomA (7.5%) was performed significantly more frequently than that of other arteries (0.56%) (p < 0.01). A laterally projected AcomA aneurysm (17.4%) was more frequently retreated than were other aneurysm types (2.3%). Cases of laterally projecting AcomA aneurysms tended to result from an incomplete clip placed using a pterional approach from the opposite side of the aneurysm projection.


Despite developments, the rates of retreatment and rerupture after surgical clipping remain similar to those reported previously. Retreatment of the AcomA was significantly more frequent than was retreatment of other arteries. Patients underwent retreatment more frequently when they were originally treated for lateral type aneurysms using a pterional approach from the opposite side of the aneurysm projection. The treatment method and evaluation modalities should be considered carefully for AcomA aneurysms in particular.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others


  1. Campi A, Ramzi N, Molyneux AJ, Summers PE, Kerr RS, Sneade M, Yarnold JA, Rischmiller J, Byrne JV (2007) Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International subarachnoid aneurysm trial (ISAT). Stroke 38:538–1544

    Article  Google Scholar 

  2. CARAT I (2006) Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment. Stroke 37:1437–1442

    Article  Google Scholar 

  3. Cui H, Wang Y, Yin Y, Wan J, Fei Z, Gao W, Jiang J (2011) Role of intraoperative microvascular Doppler in the microsurgical management of intracranial aneurysms. J Clin Ultrasound 39:27–31

    Article  PubMed  Google Scholar 

  4. Dashti R, Laakso A, Niemela M, Porras M, Hernesniemi J (2009) Microscope-integrated near-infrared indocyanine green videoangiography during surgery of intracranial aneurysms: the Helsinki experience. Surg Neurol 71:543–550

    Article  PubMed  Google Scholar 

  5. Guo LM, Zhou HY, Xu JW, Wang Y, Qiu YM, Jiang JY (2011) Risk factors related to aneurysmal rebleeding. World Neurosurg 76:292–298

    Article  PubMed  Google Scholar 

  6. Hernesniemi J, Dashti R, Lehecka M, Niemela M, Rinne J, Lehto H, Ronkainen A, Koivisto T, Jaaskelainen JE (2008) Microneurosurgical management of anterior communicating artery aneurysms. Surg Neurol 70:8–28

    Article  PubMed  Google Scholar 

  7. Ito Z (1982) The microsurgical anterior interhemispheric approach suitably applied to ruptured aneurysms of the anterior communicating artery in the acute stage. Acta Neurochir 63:85–99

    Article  CAS  PubMed  Google Scholar 

  8. Jing Z, Ou S, Ban Y, Tong Z, Wang Y (2010) Intraoperative assessment of anterior circulation aneurysms using the indocyanine green video angiography technique. J Clin Neurosci 17:26–28

    Article  PubMed  Google Scholar 

  9. Johnston SC, Dowd CF, Higashida RT, Lawton MT, Duckwiler GR, Gress DR (2008) Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the cerebral aneurysm Rerupture after treatment (CARAT) study. Stroke 39:120–125

    Article  PubMed  Google Scholar 

  10. Li H, Pan R, Wang H, Rong X, Yin Z, Milgrom DP, Shi X, Tang Y, Peng Y (2013) Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke 44:29–37

    Article  PubMed  Google Scholar 

  11. Mery FJ, Amin-Hanjani S, Charbel FT (2008) Is an angiographically obliterated aneurysm always secure? Neurosurgery 62:979–982

    Article  PubMed  Google Scholar 

  12. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R (2002) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274

    Article  PubMed  Google Scholar 

  13. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809–817

    Article  Google Scholar 

  14. Oda J, Kato Y, Chen SF, Sodhiya P, Watabe T, Imizu S, Oguri D, Sano H, Hirose Y (2011) Intraoperative near-infrared indocyanine green-videoangiography (ICG-VA) and graphic analysis of fluorescence intensity in cerebral aneurysm surgery. J Clin Neurosci 18:1097–1100

    Article  PubMed  Google Scholar 

  15. Raabe A, Nakaji P, Beck J, Kim LJ, Hsu FP, Kamerman JD, Seifert V, Spetzler RF (2005) Prospective evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery. J Neurosurg 103:982–989

    Article  PubMed  Google Scholar 

  16. Satoh A, Nakamura H, Kobayashi S, Miyata A, Tokunaga H, Wada M, Watanabe Y (2002) Surgical approaches and techniques for anterior communicating artery aneurysms: from angioanatomical point of view. Surg Cereb Stroke (Jpn) 30:240–246

    Article  Google Scholar 

  17. Sekhar LN, Natarajan SK, Britz GW, Ghodke B (2007) Microsurgical management of anterior communicating artery aneurysms. Neurosurgery 61:273–290

    PubMed  Google Scholar 

  18. Siasios I, Kapsalaki EZ, Fountas KN (2012) The role of intraoperative micro-Doppler ultrasound in verifying proper clip placement in intracranial aneurysm surgery. Neuroradiology 54:1109–1118

    Article  PubMed  Google Scholar 

  19. Suzuki M, Fujisawa H, Ishihara H, Yoneda H, Kato S, Ogawa A (2008) Side selection of pterional approach for anterior communicating artery aneurysms -surgical anatomy and strategy. Acta Neurochir 150:31–39

    Article  CAS  PubMed  Google Scholar 

  20. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J (1988) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:604–607

    Article  PubMed  Google Scholar 

  21. Yasargil M (1984) Microneurosurgery. Georg Thieme Verlag I, Stuttgart, pp 5–168

    Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Yoshiro Ito.

Ethics declarations

Conflict of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.


No funding was received for this research.

Ethical approval

This study was approved by the Institutional Ethics Committee at Tsukuba Medical Center Hospital.

Additional information


This interesting report shows that despite the introduction of fluorescence microangiography using ICG and microDoppler, complete aneurysm exclusion remains a challenge and in particular in the complex anatomy of the anterior communication artery. It emphasizes the need for an intraoperative assessment of the treatment quality and multidisciplinary collaboration. Although the risk of rebleeding and further degradation of the neurological condition of the patients is very low, the community should persevere, improving the case selection for each different treatment modality or combination thereof and further developing new techniques. In the light of such low failure rates, multicenter collaborations are mandatory to be able to demonstrate statistically significant progresses quickly.

Philippe Bijlenga

Geneva, Switzerland

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ito, Y., Yamamoto, T., Ikeda, G. et al. Early retreatment after surgical clipping of ruptured intracranial aneurysms. Acta Neurochir 159, 1627–1632 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: