Residual Cerebral Aneurysms After Microsurgical Clipping: A New Scale, an Agreement Study, and a Systematic Review of the Literature

World Neurosurg. 2019 Jan;121:e302-e321. doi: 10.1016/j.wneu.2018.09.100. Epub 2018 Sep 24.


Objective: The surgical repair of a cerebral aneurysm does not always lead to complete occlusion. A standardized repeatable method of reporting results of surgical clipping is desirable. Our purpose was to systematically review methods of classifying aneurysm remnants, provide a new scale with precise definitions of categories, and perform an agreement study to assess the variability in adjudicating remnants after aneurysm clipping.

Methods: A systematic review was performed to identify ways to report angiographic results of surgical clipping between 1963 and 2017. Postclipping angiographic results of 43 patients were also independently evaluated by 10 raters of various experience and backgrounds using a new 4-category scale. Agreement between responses were analyzed using κ statistics.

Results: The systematic review yielded 63 articles with 37 different nomenclatures using 2-6 categories. The reliability of judging the presence of an aneurysm remnant on catheter angiography was studied only twice, with only 2 raters each time, with contradictory results. Interobserver agreement using the new 4-category scale was moderate (κ = 0.52; 95% confidence interval, 0.43-0.62) for all observers, but improved to substantial (κ = 0.62; 95% confidence interval, 0.47-0.76) when results were dichotomized (grade 0/1 vs. 2/3).

Conclusions: Various classification schemes to evaluate angiographic results after surgical clipping exist in the literature, but they lack standardization. Adjudication using fewer, better defined categories may yield more reliable agreement.

Keywords: Agreement; Classification; Reliability; Residual aneurysm; Surgical clipping.

Publication types

  • Systematic Review

MeSH terms

  • Aneurysm, Ruptured / surgery
  • Cerebral Angiography
  • Female
  • Humans
  • Intracranial Aneurysm / surgery*
  • Male
  • Microsurgery / instrumentation
  • Microsurgery / methods*
  • Middle Aged
  • Neurosurgical Procedures / instrumentation
  • Neurosurgical Procedures / methods
  • Observer Variation
  • Surgical Instruments