Techniques and long-term outcomes of cotton-clipping and cotton-augmentation strategies for management of cerebral aneurysms

Abstract

obJective To address the challenges of microsurgically treating broad-based, frail, and otherwise complex aneurysms that are not amenable to direct clipping, alternative techniques have been developed. One such technique is to use cotton to augment clipping ("cotton-clipping" technique), which is also used to manage intraoperative aneurysm neck rupture, and another is to reinforce unclippable segments or remnants of aneurysm necks with cotton ("cottonaugmentation" technique). This study reviews the natural history of patients with aneurysms treated with cotton-clipping and cotton-augmentation techniques. methods The authors queried a database consisting of all patients with aneurysms treated at Barrow Neurological Institute in Phoenix, Arizona, between January 1, 2004, and December 31, 2014, to identify cases in which cotton-clipping or cotton-augmentation strategies had been used. Management was categorized as the cotton-clipping technique if cotton was used within the blades of the aneurysm clip and as the cotton-clipping technique if cotton was used to reinforce aneurysms or portions of the aneurysm that were unclippable due to the presence of perforators, atherosclerosis, or residual aneurysms. Data were reviewed to assess patient outcomes and annual rates of aneurysm recurrence or hemorrhage after the initial procedures were performed. results The authors identified 60 aneurysms treated with these techniques in 57 patients (18 patients with ruptured aneurysms and 39 patients with unruptured aneurysms) whose mean age was 53.1 years (median 55 years; range 24-72 years). Twenty-three aneurysms (11 cases of subarachnoid hemorrhage) were treated using cotton-clipping and 37 with cotton-augmentation techniques (7 cases of subarachnoid hemorrhage). In total, 18 patients presented with subarachnoid hemorrhage. The mean Glasgow Outcome Scale (GOS) score at the time of discharge was 4.4. At a mean follow-up of 60.9 ± 35.6 months (median 70 months; range 10-126 months), the mean GOS score at last follow-up was 4.8. The total number of patient follow-up years was 289.4. During the follow-up period, none of the cotton-clipped aneurysms increased in size, changed in configuration, or rebled. None of the patients experienced early rebleeding. The annual hemorrhage rate for aneurysms treated with cotton-augmentation was 0.52% and the recurrence rate was 1.03% per year. For all patients in the study, the overall risk of hemorrhage was 0.35% per year and the annual recurrence rate was 0.69%. coNclusioNs Cotton-clipping is an effective and durable treatment strategy for intraoperative aneurysm rupture and for management of broad-based aneurysms. Cotton-augmentation can be safely used to manage unclippable or partially clipped intracranial aneurysms and affords protection from early aneurysm re-rupture and a relatively low rate of late rehemorrhage.

Clip-wrapping of ruptured blood blister-like aneurysms of the internal carotid artery

“…Before the introduction of Gore-Tex as an alternative technique for clip-wrapping, the use of cotton to aid clipping ("cotton-clipping" technique) was commonly used to manage intraoperative aneurysm neck rupture [31]. Lee et al [32] reported their experience of using clip-wrapping with cellulose fabric (Bemsheet®) in 18 patients with ruptured ICA BBAs.…”

Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results

“…Therefore, the idea of combining clipping and wrapping arises. An array of techniques to perform COW have been proposed;9, 10, 25, 27, 28, 29, 30, 33, 44, 60, 61, 62, 63, 64 however, it is difficult to evaluate the efficacy and outcomes of these methods as a single entity. For example, some groups used clipping to fixate only wrapping material covering the BBA without including the artery wall 30, 32.…”

Surgery of Giant Aneurysm

“…The presence of perianeurysmal edema, which is most often found in the MCA circulation, may complicate the microsurgical clipping [16].…”