Results of surgical clipping in a neurointerventional dominant department.

Objectives: It has been 10 years since the publication of International Subarachnoid Aneurysm Trial (ISAT) (1-3) and the first-line treatment for cerebral aneurysms in many UK neurosurgical centres is endovascular occlusion. Local audit has shown a significant reduction in surgical clipping cases since 2002, with a fall from over 150 cases per year pre ISAT, to approximately 25 cases per year currently. More so the cases referred for surgical occlusion represent more challenging lesions. With such a reduction in surgical numbers we felt it prudent to review our recent surgical outcomes.

Design: Retrospective analysis of prospectively collected data.

Subjects: 47 patients (32 females, 15 males), mean age: 53 (range, 29-74) years underwent surgical clipping of cerebral aneurysms from January 2012 to September 2013.

Methods: Case notes, neuroradiology reports and cerebral angiograms were reviewed. Patient outcome was stratified according to Glasgow Outcome Score; 4-5 good outcome and 1-3 poor outcome.

Results: Of the aneurysms clipped, 40 patients had suffered a subarachnoid haemorrhage and 7 were treated for unruptured aneurysms. The reasons for referral for surgical clipping were the presence of an aneurysmal clot 9 (19%), 'failed coiling' 16 (34%) and unsuitability for endovascular intervention due to anatomical considerations 22 (47%). A good outcome was recorded in 20/22 (91%) of patients who underwent clipping for anatomical reasons, 11/16 (69%) of patients who failed endovascular treatment and 5/9 (56%) of patients with an aneurysmal clot (p = 0.05). Of 31 aneurysms with post clipping angiographic studies, 28 (90%) had complete or satisfactory aneurysm obliteration.

Conclusions: In the current era of neurointerventional dominance, the case mix undergoing microsurgical clipping is more challenging than the pre-ISAT cohort; however, post-procedural angiography has demonstrated a relatively high obliteration rate. It is reassuring that good neurological outcomes were observed in patients clipped for anatomical reasons.