Elsevier

World Neurosurgery

Volume 81, Issues 5–6, May–June 2014, Pages 752-764
World Neurosurgery

Peer-Review Report
Microsurgical Management of Giant Intracranial Aneurysms: A Single Surgeon Experience from Louisiana State University, Shreveport

https://doi.org/10.1016/j.wneu.2012.12.010Get rights and content

Background

Surgical management of giant aneurysms is challenging because of multiple factors: aneurysm size, wide neck, thrombosis, and calcification. The risk of ischemic complications is higher when compared with smaller aneurysms. We present our surgical experience of clipping these difficult aneurysms.

Methods

A total of 59 giant intracranial aneurysms underwent surgical clipping by a single surgeon over the last 2 decades. The case records of these patients were retrospectively reviewed to evaluate the operative outcome. The study was approved by the Institutional Review Board of the Louisiana State University Health Sciences Center, Shreveport, in compliance with Health Insurance Portability and Accountability Act regulations.

Results

The mean age in our series was 50.57 years (range 19 to 77 years). There was a female preponderance (female–male ratio 2.47:1). Headache was the most common form of presentation (62.7%, n = 37), followed by cranial nerve deficits (32.2%, n = 19) and seizures (13.5%, n = 8). Subarachnoid hemorrhage was seen in 38.9% (n = 23). Eleven patients had posterior circulation aneurysm. At admission, 47.8% (n = 11) of the patients were in good grade (grade I and II). Multiple aneurysms were noted in 18.64% (n = 11) of cases, but none of the patients harbored more than 1 giant aneurysm. Mortality rate was 10.1% (n = 6). The majority of patients (71.9%) experienced a good outcome (Glasgow Outcome Scale score [GOS] 4 and 5) at the last follow-up. Binary logistic regression analysis was performed to find predictors of poor outcome. Poor clinical grade, ruptured aneurysm, and posterior location predicted independently for poor outcome.

Conclusions

Giant aneurysms impose a relatively higher risk of mortality and morbidity to patients. With proper case selection and appropriate surgical strategy, it is possible to achieve a favorable outcome in most cases.

Introduction

Management of giant intracranial aneurysms remains a disconcerting challenge to most neurosurgeons. The usual treatment goals are to prevent rupture/rerupture, reduce mass effect, and ensure parent vessel patency. To achieve these goals, neurosurgeons face a wide spectrum of challenges: complex anatomy (wide neck, calcification, and intranidal thrombosis), perforators emanating from within the aneurysm sac, and anatomically complex sites of aneurysm development.

The various modalities of treating these aneurysms are endovascular coiling and/or stenting 28, 31, primary or adjunct vascular bypass 22, 51, 52, proximal parent vessel occlusion/Hunterian ligation (12), and surgical clipping. Because of the reported higher rate of recanalization or residual neck, the improved outcome achieved by endovascular therapy for small aneurysms could not be extrapolated to giant aneurysm management 3, 18, 40, 41, 55, 62. The long-term results of pipeline 36, 38/neuroform 4, 14, 61 stents are awaited.

Whereas Hunterian ligation for anterior circulation aneurysm is an option, tolerance to vessel closure is unpredictable 12, 24, 30—no test protocol is able to accurately envisage delayed cerebral ischemia after permanent carotid occlusion. In the current scenario, microneurosurgery remains a viable treatment modality (5). The present study is a retrospective analysis of the indications, complications, and outcomes of single-surgeon clipping of consecutively managed giant intracranial aneurysms over 2 decades.

Section snippets

Materials and Methods

The study was approved by the Institutional Review Board of the Louisiana State University Health Sciences Center, Shreveport, in compliance with Health Insurance Portability and Accountability Act regulations. Aneurysms with an angiographic diameter ≥25 mm were considered as giant aneurysms. Magnetic resonance imaging and/or axial computed tomography were used to measure aneurysm size in case of thrombotic aneurysms.

During a 20-year period from October 1990 to October 2011, 848 aneurysms were

Outcomes

In cases of ruptured aneurysms, preoperative neurological assessment was performed using the Hunt and Hess subarachnoid hemorrhage scale, and for unruptured aneurysms a detailed neurological evaluation was done. Outcomes were assessed with the Glasgow Outcome Score (GOS) at the last follow-up. A good outcome was defined as a GOS score of 5 or 4, and a poor outcome as a GOS score of 3 or less.

Demographic

The senior author (A.N.) surgically clipped a total of 59 consecutive giant intracranial aneurysms over the last 2 decades. The mean age in our series was 50.57 years (range 19 to 77 years). There was a female preponderance (female–male ratio 2.47:1). Headache was the most common form of presentation (62.7%, n = 37), followed by cranial nerve deficits (32.2%, n = 19) and seizures (13.5%, n = 8). Subarachnoid hemorrhage was seen in 38.9% (n = 23). Eleven patients had posterior circulation

Discussion

The optimal strategy for the management of giant intracranial aneurysms is not very clear. Some propose surgical clipping as a first line of treatment 5, 19, 53, 57. In accordance with the results of the International Subarachnoid Aneurysm Trial, endovascular coiling of aneurysms is favored at many centers 16, 48. However, in a recent critical review by Parkinson et al. (45), the mean complete occlusion rate in giant intracranial aneurysms was only 57%, with a mortality rate of 7.7%. Parent

Conclusions

In properly selected patients, surgical clipping of giant intracranial aneurysms offers long-term favorable outcomes in most cases. It ensures complete aneurysm occlusion as well as parent vessel patency in an overwhelming majority of cases. As we await long-term data regarding neuroform/pipeline stents, surgical clipping should be considered the primary approach for the management of giant supraclinoid and posterior circulation aneurysms.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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