Microsurgical and Endovascular Treatment of Large and Giant Aneurysms of the Anterior Circulation: A Systematic Review

Overview

Journal Brain Spine

Specialty Neurology

Date 2024 Jul 29

PMID 39071454

Authors

Alejandra Mosteiro

Leire Pedrosa

Marta Codes

Luis Reyes

Mariano Werner

Sergio Amaro

Joaquim Ensenat

Ana Rodriguez-Hernandez

Marlien Aalbers

Jeroen Boogaarts

Ramon Torne

Affiliations

Soon will be listed here.

Abstract

Introduction: Large and Giant intracranial aneurysms (LGIAs) have become the paradigm for which endovascular techniques do not provide satisfactory results. Yet, microsurgery is followed by non-negligible rates of morbimortality. This scenario may have changed since the introduction of flow-diversion devices.

Research Question: Contemporary and standardised revision on microsurgical and endovascular results, with emphasis on anterior circulation LGIAs.

Materials And Methods: A systematic literature search was conducted in two databases (PubMed and Embase) on treatment outcomes of LGIAs of the anterior circulation, after the introduction of flow-diverters 2008/01/01, till 2023/05/20. Small case series (<5 cases), series including >15% of posterior circulation aneurysms, and studies not reporting clinical and/or angiographic outcomes were excluded.

Results: 44 relevant studies (observational cohorts) were identified, including 2923 LGIAs predominantly from anterior circulation. Mean follow-up 22 (±20) months. 1494 (51%) LGIAs were treated endovascularly and 1427 (49%) microsurgically. According to the random effects model, pooled rates of favourable clinical outcomes were 85.8% (CI 95% 82.6-88.4), complete occlusion 69.4% (CI 95% 63.7-7.46), complications 19.6% (CI 95%16-23.9) and mortality 5.6% (CI 95% 4.4-7.1). Focusing on type of treatment, occlusion rates are higher with microsurgical (842/993, 85% vs 874/1,299, 67%), although good outcomes are slightly more frequent with endovascular (1045/1,135, 92% vs 1120/1,294, 87%).

Discussion And Conclusions: According to contemporary data about occlusion rates, functional outcomes, and complications, primary or secondary treatment of LGIAs of the anterior circulation seems justified. Microsurgical occlusion rates are higher in LGIAs. An expert consensus on reporting complications and management strategies is warranted.

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References

Barrow D, Alleyne C . Natural history of giant intracranial aneurysms and indications for intervention. Clin Neurosurg. 1995; 42:214-44. View

Oishi H, Teranishi K, Yatomi K, Fujii T, Yamamoto M, Arai H . Flow Diverter Therapy Using a Pipeline Embolization Device for 100 Unruptured Large and Giant Internal Carotid Artery Aneurysms in a Single Center in a Japanese Population. Neurol Med Chir (Tokyo). 2018; 58(11):461-467. PMC: 6236209. DOI: 10.2176/nmc.oa.2018-0148. View

Abdelkhalek H, Abdelhameed E, Zakarea A, Malky I . Predictors of flow diverter stent in large and giant unruptured intracranial aneurysms, single-center experience. Neurol Sci. 2022; 43(11):6399-6405. PMC: 9616764. DOI: 10.1007/s10072-022-06336-w. View

Gao X, Liang G, Li Z, Wei X, Cao P . A single-centre experience and follow-up of patients with endovascular coiling of large and giant intracranial aneurysms with parent artery preservation. J Clin Neurosci. 2012; 19(3):364-9. DOI: 10.1016/j.jocn.2011.03.038. View

Lv N, Ma H, Zhou Y, Li Z, Zeng Y, Li Q . Coiling followed by staged flow diversion for large and giant intracranial aneurysms. Front Neurol. 2022; 13:1024447. PMC: 9751354. DOI: 10.3389/fneur.2022.1024447. View

Khurana V, Piepgras D, Whisnant J . Ruptured giant intracranial aneurysms. Part I. A study of rebleeding. J Neurosurg. 1998; 88(3):425-9. DOI: 10.3171/jns.1998.88.3.0425. View

Kumar N, Ladner T, Kahn I, Zuckerman S, Baker C, Skaletsky M . Parent vessel occlusion for treatment of cerebral aneurysms: Is there still an indication? A series of 17 patients. J Neurol Sci. 2016; 372:250-255. DOI: 10.1016/j.jns.2016.11.057. View

Dengler J, Maldaner N, Glasker S, Endres M, Wagner M, Malzahn U . Outcome of Surgical or Endovascular Treatment of Giant Intracranial Aneurysms, with Emphasis on Age, Aneurysm Location, and Unruptured Aneuryms--A Systematic Review and Meta-Analysis. Cerebrovasc Dis. 2016; 41(3-4):187-98. DOI: 10.1159/000443485. View

Ishishita Y, Tanikawa R, Noda K, Kubota H, Izumi N, Katsuno M . Universal extracranial-intracranial graft bypass for large or giant internal carotid aneurysms: techniques and results in 38 consecutive patients. World Neurosurg. 2013; 82(1-2):130-9. DOI: 10.1016/j.wneu.2013.02.063. View

10.

Imai H, Watanabe K, Miyagishima T, Yoshimoto Y, Kin T, Nakatomi H . The outcome of a surgical protocol based on ischemia overprotection in large and giant aneurysms of the anterior cerebral circulation. Neurosurg Rev. 2016; 39(3):505-17. PMC: 4904025. DOI: 10.1007/s10143-016-0721-z. View

11.

Chalouhi N, Thakkar V, Tjoumakaris S, Gonzalez L, Hasan D, Rosenwasser R . Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience. J Clin Neurosci. 2014; 21(8):1424-7. DOI: 10.1016/j.jocn.2013.11.052. View

12.

Kim B, Shin Y, Baik M, Lee D, Jeon P, Baik S . Pipeline Embolization Device for Large/Giant or Fusiform Aneurysms: An Initial Multi-Center Experience in Korea. Neurointervention. 2016; 11(1):10-7. PMC: 4781911. DOI: 10.5469/neuroint.2016.11.1.10. View

13.

Locksley H . Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg. 1966; 25(2):219-39. DOI: 10.3171/jns.1966.25.2.0219. View

14.

Ohta T, Nakahara I, Ishibashi R, Matsumoto S, Gomi M, Miyata H . The maze-making and solving technique for coil embolization of large and giant aneurysms. AJNR Am J Neuroradiol. 2014; 36(4):744-50. PMC: 7964313. DOI: 10.3174/ajnr.A4198. View

15.

Dengler J, Rufenacht D, Meyer B, Rohde V, Endres M, Lenga P . Giant intracranial aneurysms: natural history and 1-year case fatality after endovascular or surgical treatment. J Neurosurg. 2019; 134(1):49-57. DOI: 10.3171/2019.8.JNS183078. View

16.

Cantore G, Santoro A, Guidetti G, Delfinis C, Colonnese C, Passacantilli E . Surgical treatment of giant intracranial aneurysms: current viewpoint. Neurosurgery. 2008; 63(4 Suppl 2):279-89. DOI: 10.1227/01.NEU.0000313122.58694.91. View

17.

Sluzewski M, Menovsky T, van Rooij W, Wijnalda D . Coiling of very large or giant cerebral aneurysms: long-term clinical and serial angiographic results. AJNR Am J Neuroradiol. 2003; 24(2):257-62. PMC: 7974128. View

18.

Mizutani T, Miki Y, Kojima H, Suzuki H . Proposed classification of nonatherosclerotic cerebral fusiform and dissecting aneurysms. Neurosurgery. 1999; 45(2):253-9; discussion 259-60. DOI: 10.1097/00006123-199908000-00010. View

19.

Zhu W, Liu P, Tian Y, Gu Y, Xu B, Chen L . Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies. Acta Neurochir (Wien). 2013; 155(8):1481-91. PMC: 3718994. DOI: 10.1007/s00701-013-1751-8. View

20.

Nakajima H, Kamiyama H, Nakamura T, Takizawa K, Tokugawa J, Ohata K . Direct surgical treatment of giant middle cerebral artery aneurysms using microvascular reconstruction techniques. Neurol Med Chir (Tokyo). 2012; 52(2):56-61. DOI: 10.2176/nmc.52.56. View