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Background Since its approval by the US Food and Drug Administration (FDA) in 2018, the flow disruptor Woven EndoBridge (WEB) device has become increasingly popular for the endovascular treatment of unruptured and ruptured cerebral aneurysms. However, the occlusion rates seem rather low and the retreatment rates rather high compared to other treatment methods. For initially ruptured aneurysms, a retreatment rate of 13 % has been reported. A variety of retreatment strategies has been proposed; however, there is a paucity of data concerning microsurgical clipping of WEB-pretreated aneurysms, especially previously ruptured ones. Thus, we present a single-center series of five ruptured aneurysms treated with the WEB device and retreated with microsurgical clipping. Methods A retrospective study including all patients presenting with a ruptured aneurysm undergoing WEB treatment at our institution between 2019 and 2021 was performed. Subsequently, all patients with an aneurysm remnant or recurrence of the target aneurysm retreated with microsurgical clipping were identified. Results Overall, five patients with a ruptured aneurysm treated with WEB and retreated with microsurgical clipping were included. Besides one basilar apex aneurysm, all aneurysms were located at the anterior communicating artery (AComA) complex. All aneurysms were wide-necked with a mean dome-to-neck ratio of 1.5. Clipping was feasible and safe in all aneurysms, and complete occlusion was achieved in 4 of 5 aneurysms. Conclusions Microsurgical clipping for initially ruptured WEB-treated aneurysms is a feasible, safe, and effective treatment method in well-selected patients.

Bipolar coagulation was historically described as a method for dome or neck remodeling, but concerns about rupture kept it underused. Yet carefully applied, low-power bipolar bursts can safely shrink or stiffen aneurysm walls, improving clip access in select challenging cases. This study aims to systematically evaluate how bipolar coagulation is used during intracranial aneurysm clipping, including its indications, intraoperative roles, and impact on surgical exposure and postoperative outcomes. We retrospectively analyzed 50 consecutive patients who underwent microsurgical clipping of intracranial saccular aneurysms in which bipolar coagulation was deliberately employed. High-resolution surgical videos were reviewed to document the timing (pre-clip vs post-clip), target (dome vs neck), and purpose (remodeling, shrinkage, dissection assistance, or repair). Aneurysm morphology, rupture status, clip strategy, and perioperative variables were obtained from operative and radiological records. Patients were monitored clinically and radiographically at standardized intervals up to 24 months. Bipolar techniques were applied for neck remodeling in 31 patients (62%), dome coagulation in 30 patients (60%), post-clip coagulation in 29 patients (58%). Sole bipolar coagulation combined with cotton wrapping was used in 1 patient (2%). No statistically significant differences were observed among groups in preoperative WFNS scores (p = 0.20), discharge WFNS scores (mean 1.38 ± 1.07; p = 0.71), number of clips used (p = 0.56), mortality (p = 0.93), or indication distribution (p = 5.45). Early postoperative imaging demonstrated complete aneurysm obliteration in 48 of 50 patients (96%), while residual aneurysm was detected in 2 patients (4%). Overall mortality during follow-up was 6% (3/50), with no deaths attributable to surgical technique; all deaths were related to vasospasm. Selective, low-power bipolar coagulation was used as an adjunct during aneurysm clipping without bipolar-related intraoperative rupture in this series. Its controlled use can enhance visualization, optimize clip positioning, and expand treatment options in anatomically challenging aneurysms.

Quality of life (QoL) is one of the parameters that characterize the treatment success after aneurysmal subarachnoid hemorrhage, along with overall survival and independent living without the need for care. Thus, the main aim of this research was to evaluate the quality of life of patients after endovascular or microsurgical treatment of ruptured cerebral aneurysms. This study was performed at the Jena University Hospital in Germany. A total of 32 patients completed the German version of the WHO QoL Questionnaire during routine follow-up visits at our neurovascular outpatient clinic between January and September 2024. Analyses were stratified by the type of treatment. Patients who underwent endovascular treatment have better subjective reports of QoL in the psychological and environment domains, whereas those who underwent microsurgical clipping showed better outcomes in physical and social domains. Aneurysm location did not significantly impact QoL. To conclude, these findings suggest that different treatment modalities influence distinct aspects of QoL. Implementing treatment-tailored strategies, alongside comprehensive management of subarachnoid hemorrhage-related risks, may further enhance recovery and optimize functional outcomes.

BackgroundWhile both endovascular coiling and microsurgical clipping are extensively used and recognized procedures, they have different advantages and disadvantages in terms of procedural risks, long-term neurological prognosis, and complications. This meta-analysis compares the effectiveness and safety of endovascular coiling with microsurgical clipping in patients with ruptured anterior circulation aneurysms.MethodsA comprehensive search was conducted on PubMed, Web of Science, Scopus, and Cochrane Library until February 2025. Studies comparing endovascular coiling and microsurgical clipping for managing ruptured anterior circulation aneurysms were retrieved. The main endpoint was all-cause mortality. Secondary endpoints included good outcomes, poor outcome complications, and operative outcomes. The risk ratios (RR) and mean differences (MD) with their 95% confidence interval (CI) were computed employing random-effects models.Results34 studies, incorporating 4,107 patients, met the inclusion criteria. Coiling revealed a higher risk of all-cause mortality (RR: 1.291 with 95% CI [1.054, 1.582]), primarily in short-term follow-up (RR: 1.50 with 95% CI [1.15, 1.95]). However, no significant differences were observed in mortality rates according to the specific aneurysm location. Neither poor outcome (RR: 0.90 with 95% CI [0.74, 1.08]) nor good outcome (RR: 1.06 with 95% CI [0.98, 1.14]) differed significantly between treatments. Coiling demonstrated reduced risks of intraoperative rupture (RR: 0.55 with 95% CI [0.34, 0.88]), ischemic infarction (RR: 0.76 with 95% CI [0.6, 0.97]), and seizure (RR: 0.42 with 95% CI [0.18, 0.97]). However, coiling was associated with lower complete occlusion rates (RR: 0.76 with 95% [CI 0.66, 0.87]) and higher incomplete occlusion (RR: 2.98 with 95% CI [2.03, 4.38]).ConclusionEndovascular coiling for ruptured anterior circulation aneurysms is associated with fewer perioperative complications, including reduced risks of intraoperative rupture, ischemic infarction, and seizures. However, it carries a higher risk of short-term mortality, lower rates of complete occlusion, and higher rates of incomplete occlusion compared with microsurgical clipping. Despite these differences, both techniques achieve comparable long-term functional outcomes, supporting an individualized, patient-centered treatment approach.

Background Proximal arterial control is critical for safe and effective microsurgical clipping of ophthalmic segment aneurysms (OSAs). Traditionally, this is achieved via neck dissection and temporary clamping of the cervical internal carotid artery (ICA). Advances in endovascular technology have introduced temporary balloon occlusion (TBO) as a potentially less invasive alternative. This study aims to assess the utility of TBO during microsurgical clipping of OSAs. Methods A retrospective review was conducted of all patients at a single institution who underwent microsurgical OSA clipping with planned TBO. Patient demographics, presentation, aneurysm morphology, occlusion outcomes, complications, recurrence, and functional outcomes based on modified Rankin score (mRS) at follow-up were evaluated. Patients who underwent balloon inflation for proximal control (+ TBO) were compared with those who did not (-TBO). Results A total of 34 patients with 35 OSAs were included. A temporary balloon guide catheter was successfully navigated to the cervical carotid in all cases. TBO was performed in 19 patients (20 aneurysms) during aneurysm clipping. Aneurysm sizes ranged from 2.8 to 18.0 mm (mean: 6.7 mm), with neck sizes ranging from 1.6 to 8.1 mm (mean: 4.2 mm). The + TBO group had a significantly higher proportion of wide-necked aneurysms (> 4 mm) compared to the -TBO group (55.0% vs. 26.7%; p = 0.008) and more frequently required anterior clinoidectomy (84.2% vs. 46.7%; p = 0.020). Complete or near-complete (< 2 mm remnant) aneurysm occlusion was achieved in all cases. There was one complication (2.9%) with permanent sequela and median mRS at follow-up was 0. There were no significant differences in complication rates or functional outcomes between the + TBO and -TBO groups. Conclusion Endovascular-assisted TBO is a safe and effective minimally invasive alternative to open neck dissection for achieving proximal control during OSA clipping. TBO may be particularly advantageous for managing wide-neck aneurysms.

Background Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported. Methods Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice. Results Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively ( p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome. Conclusions Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.

There is an ongoing lack of consensus among clinicians regarding on the optimal aneurysmal subarachnoid hemorrhage (aSAH) management approach between endovascular coiling and microsurgical clipping. Comprehensive literature search for randomized controlled trials (RCTs) was conducted in Medline and Cochrane databases until January 1st, 2023 without language constraints. Effectivity outcomes included one-year mortality, one-year poor outcomes, and one-year complete aneurysmal occlusion, while safety outcomes comprised the incidence of vasospasms, rebleeding, post-operative complications, and cerebral ischemia. Eight RCTs, involving 3585 aSAH patients, underwent comprehensive quantitative analysis. Among them, 1792 underwent endovascular coiling and 1773 patients had microsurgical clipping. Regarding effectivity, the rates of one-year mortality (OR: 0.79, 95% CI: 0.61–1.03, p = 0.08) exhibited no significant difference. However, endovascular coiling demonstrated an inferior one-year complete aneurysmal occlusion rate (OR: 0.33, 95% CI: 0.21–0.53, p < 0.00001), although with significantly lower rates of poor outcomes (OR: 0.68, 95% CI: 0.57–0.81, p < 0.00001) compared to the microsurgical clipping group. As for safety, endovascular coiling group exhibited lower rates of vasospasm (OR: 0.58, 95% CI: 0.36–0.92, p = 0.02), post-operative complications (OR: 0.40, 95% CI: 0.23–0.71, p = 0.02), and cerebral ischemia (OR: 0.36, 95% CI: 0.20–0.63, p = 0.0004). No significant effect on the incidence of rebleeding was observed (OR: 1.09, 95% CI: 0.73–1.63, p = 0.68). Endovascular coiling proves superior and safer for aSAH patients, but consideration of resources, patient condition, and surgeon preferences is crucial for selecting the optimal approach. •Clipping demonstrated a superior 1-year complete aneurysmal occlusion rate.•Coiling demonstrated significantly lower rates of 1-year poor outcomes.•Lower rates of vasospasms, post-operative complications, and cerebral ischemia in coiling.

This study aimed to evaluate age as a prognostic factor and develop a comprehensive prognostic model for patients undergoing clipping surgery for World Federation of Neurosurgical Societies (WFNS) grade I/II aneurysmal subarachnoid haemorrhage (SAH). We retrospectively investigated 188 patients with WFNS grade I/II SAH who underwent microsurgical clipping at our institute between December 2010 and January 2020. The data of 176 patients (75 with grade I and 101 with grade II) were analysed. Data on patient demographics, aneurysm characteristics, SAH factors, surgical details, and clinical outcomes were collected. Prognostic factors were assessed using bivariate and multivariable logistic regression analyses, and recursive partitioning analysis. Favourable outcomes (mRS 0–2) were observed in 76% of patients. Age, a significant negative prognostic factor in multivariable analysis (odds ratio 0.55, 95% confidence interval 0.40–0.76, p  < 0.001), was cutoff at 70 years by the receiver operating characteristic curve. Patients aged ≤ 70 years had significantly better outcomes than those aged > 70 years (84% vs. 46%, respectively; p  < 0.001). Epileptic seizures were significantly associated with poor outcomes in older adults ( p  < 0.001). A prognostic model (favourable, intermediate, and poor) based on age and postoperative adverse events showed significantly different outcomes between age groups ( p  < 0.001). Age was a stronger prognostic factor than WFNS grading for patients with grade I/II SAH undergoing microsurgical clipping. For patients aged ≤ 70 years, precise microsurgeries with fewer complications were associated with favourable outcomes beyond WFNS grade. For older patients, postoperative intensive seizure management may prevent poor outcomes.

Superior hypophyseal artery aneurysms are rare. Symptomatic superior hypophyseal artery aneurysm commonly presents with subarachnoid hemorrhage, uncommonly with cranial nerve deficits, and very rarely with visual impairment. Microsurgical management of such aneurysms is quite complex considering the anatomical structures in the paraclinoid region. A 43-year male presented with decreased visual acuity in both eyes. The patient was diagnosed with left supraclinoid partially thrombosed unruptured aneurysm with mass effect over optic chiasm and optic nerves on magnetic resonance imaging of the brain. He underwent clipping of the aneurysm with an aneurysmectomy. At the six-month clinical follow-up, the right eye vision had significantly improved.

Studies comparing different treatment methods in patients with middle cerebral artery (MCA) aneurysms in different subgroups of onset symptoms are lacking. It is necessary to explore the safety and efficacy of open surgical treatment and endovascular therapy in patients with MCA aneurysms in a specific population. This study aimed to compare microsurgical clipping versus endovascular therapy regarding complication rates and outcomes in patients with MCA aneurysms presenting with neurological ischemic symptoms. This was a retrospective cohort study in which 9656 patients with intracranial aneurysms were screened between January 2014 and July 2022. Further, 130 eligible patients were enrolled. The primary outcome was the incidence of serious adverse events (SAEs) within 30 days of treatment, whereas secondary outcomes included postprocedural target vessel–related stroke, disabling stroke or death, mortality, and aneurysm occlusion rate. Among the 130 included patients, 45 were treated with endovascular therapy and 85 with microsurgical clipping. The primary outcome of the incidence of SAEs within 30 days of treatment was significantly higher in the clipping group [clipping: 23.5%(20/85) vs endovascular: 8.9%(4/45), adjusted OR:4.05, 95% CI:1.20–13.70; P  = 0.024]. The incidence of any neurological complications related to the treatment was significantly higher in the clipping group [clipping:32.9%(28/85) vs endovascular:15.6%(7/45); adjusted OR:3.49, 95%CI:1.18–10.26; P  = 0.023]. Postprocedural target vessel–related stroke, disabling stroke or death, mortality rate, and complete occlusion rate did not differ significantly between the two groups. Endovascular therapy seemed to be safer in treating patients with MCA aneurysms presenting with neurological ischemic symptoms compared with microsurgical clipping, with a significantly lower incidence of SAEs within 30 days of treatment and any neurological complications related to the treatment during follow-up.