This document appears to be a presentation on the risk of rupture of previously wrapped intracranial aneurysms. It discusses a clinical case of a 60-year-old woman whose aneurysm was wrapped 6 years ago. It outlines a searchable question in PICO format on the rupture rates of wrapped versus clipped aneurysms. The presentation describes searching for studies on wrapped intracranial aneurysms and summarizes the findings that the risk of rupture is greatest initially after wrapping and may resemble the natural history risk in the long term, while local complications are also a risk. It concludes that wrapping is not an ideal treatment and "unclippable" should be redefined when possible using techniques like small clips or bypass alternatives.

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Risk of rupture of previously
“wrapped” intracranial aneurysms
Macquarie Neurosurgery
Evidence Based Surgery presentation
11th July, 2013
Peter Wilson

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Clinical case
• 60 year old lady
• Smoker
• Wrapping of unruptured complex calcified
MCA aneurysm 6 years ago
• MCA infarct post-op
– Spastic hemiplegia
• Previously recommended 3 monthly CTAs

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Searchable question (PICO format)
• P = patients with previously wrapped
intracranial aneurysms
• I = wrap
• C = clipping
• O = haemorrhage / rupture rate

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Search strategy
• Intracranial aneurysm
• Wrap (or similar)
– Muslin
– Gauze
– Bandage
– Mesh

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Search results

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Summary of papers
• Few large series
• Risk of rupture greatest initially
• ?similar to natural history in long term
• Risk of local complications

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Conclusions
• Wrapping is not an ideal treatment strategy
• “Unclippable” defined by treating surgeon
– ?small clips for aneurysms <3 mm
– ?bypass alternatives