Surgical treatment of giant intracranial aneurysms: current viewpoint.
OBJECTIVE
Despite new endovascular techniques and technological advances in microsurgery, the treatment of giant intracranial aneurysms is still a daunting neurosurgical task. Many of these aneurysms have a large, calcified neck, directly involve parent and collateral branches, and are partly thrombosed. In this retrospective review, we focused our analysis on the indications for high-flow, extracranial-intracranial (EC-IC) bypass surgery using a saphenous vein graft.


METHODS
A series of 130 patients were treated between 1990 and 2004; 31 patients were managed endovascularly, and 99 patients were treated microsurgically (surgical clipping in 58 patients and high-flow EC-IC bypass followed by aneurysm trapping in 41 patients). We examined the patients' clinical records and pre- and postoperative case notes for cerebral angiographic examinations. Graft patency was verified with cerebral angiography, computed tomographic angiography, Doppler ultrasound, or graft palpation.


RESULTS
The high-flow EC-IC bypass was used for all surgically treated prepetrous aneurysms (3 patients), intracavernous aneurysms (1 patient), intracavernous aneurysms with subarachnoid extension (23 patients), as well as for some supraclinoid aneurysms (12 of the 32 patients). It was also used for 1 of the 9 aneurysms located in the carotid bifurcation and 2 of 5 vertebrobasilar circulation aneurysms. Of the 58 patients managed by surgical clipping, 4 (6.9%) died, and 51 (94.4%) improved. Of the 41 patients managed with high-flow EC-IC bypass, 4 (9.8%) died and 34 (91.9%) improved. Graft patency at the follow-up examination was 92.7%.


CONCLUSIONS
The "gold standard" for the treatment of giant aneurysms remains surgical clipping. When direct surgical clipping or endovascular repair is contraindicated, the high-flow EC-IC bypass is a viable surgical option.
Cantore
Giampaolo
G
Department of Neurological Sciences, Istituto Neurologico Mediterraneo Neuromed, Istituto di Ricovero e Cura a Carattere Scientifico, Pozzilli, Italy.
Santoro
Antonio
A
Guidetti
Giulio
G
Delfinis
Catia P
CP
Colonnese
Claudio
C
Passacantilli
Emiliano
E
D000046:Academic Medical Centers; D000368:Aged; D000465:Algorithms; D001488:Basilar Artery / Q000473:pathology / Q000601:surgery; D002536:Cerebral Arteries / Q000473:pathology / Q000601:surgery; D002548:Cerebral Revascularization / Q000009:adverse effects / Q000379:methods*; D003663:Decision Trees; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002532:Intracranial Aneurysm / Q000473:pathology / Q000601:surgery*; D008297:Male; D008866:Microsurgery / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D018579:Patient Selection; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000637:transplantation; D012720:Severity of Illness Index; D013525:Surgical Instruments; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*