The complementary multimodal treatment of recalcitrant cerebral aneurysms

Background: The main treatment of cerebral aneurysms is direct surgical clipping or endovascular coil embolization. However, some cerebral aneurysms that we reviewed in the literature are still not susceptible to a single treatment approach. These aneurysms can be referred to as complex aneurysms. Objective: We aim to report these aneurysms and share our clinical experience with their treatment and diagnosis. Methods: All cases of cerebral aneurysms treated in New York University and in Mansoura University from 2010-2021 were retrospectively reviewed. Results: 18 patients with 21 cerebral aneurysms were treated by combined surgical and endovascular modalities. Aneurysms associated with arteriovenous malformations (AVMs) in 3 patients, associated with vasospasm in 7 patients, and 3 patients had double aneurysms. A total of 18 patients with aneurysms were treated with combined endovascular and microsurgical therapy. Early angiogram (< 1 week) revealed; complete obliteration of 19 aneurysms (90%) out of a total of 21 aneurysms, residual filling was observed in 2 aneurysms (10%). Late radiological follow up (> 3 months- 2 years) revealed; a stable residual filling in one and the other case underwent retreatment. Conclusions: The recalcitrant or complex cerebral aneurysms can be better referred to as diseases rather than lesions as many clinical and anatomical factors make their treatment difficult. Endovascular and microsurgery could be complementary to each other and create a multimodal approach for treating them.