Abstract
Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery. The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases illustrating possible treatment strategies. In view of the poor natural history, active management using multiprofessional individualized approaches is required to achieve aneurysm occlusion, relief of mass effect, and obliteration of the embolic source. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available to achieve definitive treatment with acceptable morbidity. Patients harboring such lesions should be managed at high-volume cerebrovascular centers by multidisciplinary teams trained in all techniques of open and endovascular neurosurgery.
Highlights
Very large and giant intracranial aneurysms are defined as aneurysms with a diameter >20 mm and >25 mm [1] respectively
In view of the poor natural course of these lesions, aggressive treatment aiming for both aneurysm occlusion and relief of mass effect has been recommended [6, 7]
The risk-benefit assessment, will favor active therapy only when treatment is performed at high-volume cerebrovascular centers, where the capacities of both neurosurgery and neurointervention are available and individualized treatment concepts considering anatomic location, clinical presentation (SAH vs. mass effect vs. incidental presentation), patient demographics, and aneurysm morphology can be applied [6, 7]
Summary
Very large and giant intracranial aneurysms are defined as aneurysms with a diameter >20 mm and >25 mm [1] respectively. The risk-benefit assessment, will favor active therapy only when treatment is performed at high-volume cerebrovascular centers, where the capacities of both neurosurgery and neurointervention are available and individualized treatment concepts considering anatomic location (cavernous vs subarachnoid, anterior circulation vs posterior circulation), clinical presentation (SAH vs mass effect vs incidental presentation), patient demographics (age), and aneurysm morphology can be applied [6, 7]. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available for the treatment of cerebral aneurysms [8]. The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases—treated by the senior author, who has been dually trained and is cross-experienced in both microsurgical and endovascular techniques—to illustrate possible treatment strategies
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