Long-term Clinical and Angiographic Follow-up of Unclippable Wrapped Inracranial Aneurysms

Abstract

In Reply: We thank De Freitas and Choudhari et al. for their critical evaluation of our article (1). They have appropriately highlighted the salient weaknesses of our study. We welcome this opportunity to respond to their concerns and, in turn, to reiterate our philosophy on the use of wrapping techniques. The primary surgical treatment of intracranial aneurysms is clip ligation, and the superiority of clipping over wrapping is, in most cases, indisputable. During the past 10 years, we have clipped approximately 2300 aneurysms. Only 74 (3.2%) were wrapped as the primary treatment modality. The small subset that should be considered for wrapping includes fusiform and dissecting aneurysms, small blister aneurysms, and aneurysms with associated atheromatous disease or heavy calcification. For each of these subtypes, primary clip ligation risks compromise of the parent vessel and lumen of branch vessels. In such cases, wrapping should be considered as a viable alternative. We strongly caution against the use of wrapping techniques to treat ruptured aneurysms, and we regret not emphasizing this point more strongly in our article. Our own experience, along with the existing literature, indicates that rerupture rates are high in these patients. For patients with unclippable ruptured aneurysms (i.e., dissecting supraclinoid internal carotid artery aneurysms), we recommend extracranial-intracranial bypass with parent vessel sacrifice or clip-wrapping followed soon thereafter by intraluminal reinforcement with Neuroform stent (Boston Scientific/Target, Fremont, CA) stenting. The evidence is compelling that wrapping ruptured aneurysms as a solitary treatment is not a viable option. The weaknesses of our study pertaining to patients lost to follow-up and the length of follow-up were acknowledged repeatedly in the article. These weaknesses should not be diminished. However, we presented the single largest series of wrapped intracranial aneurysms reported to date. Although these data are imperfect, we are confident that continued longitudinal examination of this cohort of patients will lead to a better understanding of the safety and efficacy of wrapping techniques. Vivek Deshmukh Washington, D.C. Robert F. Spetzler Phoenix, Arizona