Management of recurrent intracranial aneurysms after coil embolization: a novel classification scheme based on angiography

OBJECTIVE Recurrent aneurysms after coil embolization remain a challenging issue. The goal of the present study was to report the authors’ experience with recurrent aneurysms after coil embolization and to discuss the radiographic classification scheme and recommended management strategy. METHODS Aneurysm treatments from a single institution over a 6-year period were retrospectively reviewed. Ninety-seven aneurysms that recurred after initial coiling were managed during the study period. Recurrent aneurysms were classified into the following 5 types based on their angiographic characteristics: I, pure recanalization inside the aneurysm sac; II, pure coil compaction without aneurysm growth; III, new aneurysm neck formed without coil compaction; IV, new aneurysm neck formed with coil compaction; and V, newly formed aneurysm neck and sac. RESULTS Aneurysm recurrences resulted in rehemorrhages in 6 cases (6.2%) of type III–V aneurysms, but in none of type I–II aneurysms. There was a significantly higher proportion of ophthalmic artery aneurysms and complex internal carotid artery aneurysms presenting as types I and II than presented as the other 3 types (63.3% vs 16.4%, p < 0.001). In contrast, for posterior communicating artery aneurysms and anterior communicating artery aneurysms, a higher proportion of type III–V aneurysms was observed than for the other 2 types, but without a significant difference in the multivariate model (56.7% vs 23.3%). In addition, giant (> 25 mm) aneurysms were more common among type I and II lesions than among type III and IV aneurysms (36.7% vs 9.0%, p = 0.001), which exhibited a higher proportion of small (< 10 mm) lesions (65.7% vs 13.3%, p < 0.001). A single reembolization procedure was sufficient to occlude 80.0% of type I recurrences and 83.3% of type II recurrences from coil compaction but only 65.6% of type III–V recurrences from aneurysm regrowth. CONCLUSIONS Aneurysm size and location represent the determining factors of the angiographic recurrence types. Type I and II recurrences were safely treated by reembolization, whereas type III–V recurrences may be best managed surgically when technically feasible.