Routine cerebral angiography after surgery for saccular aneurysms: is it worth it?

Objective: The objective of this study was to determine whether an angiographically proven rate of saccular intracranial aneurysm occlusion after surgical clipping suggests that postoperative angiography should continue to be used routinely or should be supplanted by intraoperative angiography. These data also should establish a basis for comparing surgery with new endovascular methods of treatment.
Methods: During a 3.5-year period, a consecutive series of 622 patients (955 aneurysms, 808 of which were surgically clipped) who underwent postoperative angiography were studied retrospectively. This series comprised 493 ruptured and 315 unruptured aneurysms.
Results: Complete aneurysm closure was achieved in 88% of aneurysms, a neck remnant was discovered in 9%, and a fundus remnant was revealed in 3%. Of 493 ruptured aneurysms, 86% were completely occluded. Of 315 unruptured aneurysms, 91% were completely occluded. The results for clipping of complex aneurysms, i.e., posterior circulation or large to giant aneurysms, were significantly inferior to those for small and anterior circulation aneurysms. In one-third of the large and giant aneurysms, a part of the base was left intentionally because of calcifications or strong wall or to prevent occlusion of any branches. In the series, a significant 5% complication rate of major vessel occlusion was detected.
Conclusion: Our retrospective analysis revealed that ruptured, posterior circulation, and large/giant aneurysms are more prone to incomplete clipping. Therefore, these aneurysms require postoperative if not intraoperative evaluation with angiography. Many clippings of anterior circulation aneurysms experience unexpected failures, which suggests that intraoperative angiography could be beneficial. This series, which has no selection bias, can be used as a basis to compare the results of other series reporting surgical or endovascular treatment.