Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study

Clinical article

Erik F. Hauck M.D., Ph.D., Bryan Wohlfeld M.D., Babu Guai Welch M.D., Jonathan A. White M.D. and Duke Samson M.D.
View More View Less
  • Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Patients with very large or giant unruptured intracranial aneurysms present with ischemic stroke and progressive disability. The aneurysm rupture risk in these patients is extreme—up to 50% in 5 years. In this study the authors investigated the outcome of surgical treatment for these very large aneurysms in the anterior circulation.

Methods

Clinical data on 62 patients who underwent surgery for unruptured aneurysms (20–60 mm) between 1998 and 2006 were reviewed.

Results

Complete aneurysm occlusion (100%) was achieved in 90% of cases, near complete occlusion (90–99%) in 5%. The surgical risk in patients younger than 50 years of age was 8% (Glasgow Outcome Scale score of 1 or 3 within 1 year after surgery). In older patients, the risk increased with advancing age.

Conclusions

The treatment of very large or giant unruptured intracranial aneurysms is hazardous and complex and thus best performed only at major cerebrovascular centers with an experienced team of neurosurgeons, interventional neuroradiologists, neurologists, and neuroanesthesiologists. Surgery, with acceptable risks and excellent occlusion rates, is typically the treatment of choice in patients younger than 50 years of age. In older patients, the benefits of endovascular treatment versus surgery versus no treatment must be carefully weighed individually. Minimizing temporary occlusion and the consequent use of intraoperative angiography may help reduce surgical complications.

Abbreviations used in this paper:ACA = anterior cerebral artery; CI = confidence interval; GOS = Glasgow Outcome Scale; ICA = internal carotid artery; ISUIA = International Study of Unruptured Intracranial Aneurysms; MCA = middle cerebral artery; OR = odds ratio; PCoA = posterior communicating artery; TIA = transient ischemic attack.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Erik F. Hauck, M.D., Ph.D., Department of Neurosurgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390. email: erikhauck@gmx.de.
  • 1

    Benitez RP, , Silva MT, , Klem J, , Veznedaroglu E, & Rosenwasser RH: Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils. Neurosurgery 54:13591368, 2004

    • Search Google Scholar
    • Export Citation
  • 2

    Chang HS: Simulation of the natural history of cerebral aneurysms based on data from the International Study of Unruptured Intracranial Aneurysms. J Neurosurg 104:188194, 2006

    • Search Google Scholar
    • Export Citation
  • 3

    Deshaies EM, , Adamo MA, & Boulos AS: A prospective singlecenter analysis of the safety and efficacy of the hydrocoil embolization system for the treatment of intracranial aneurysms. J Neurosurg 106:226233, 2007

    • Search Google Scholar
    • Export Citation
  • 4

    Drake CG: Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg 26:1295, 1979

  • 5

    Drake CG, , Peerless SJ, & Ferguson GG: Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation. J Neurosurg 81:656665, 1994

    • Search Google Scholar
    • Export Citation
  • 6

    Fiorella D, , Albuquerque FC, , Deshmukh VR, & McDougall CG: Usefulness of the Neuroform stent for the treatment of cerebral aneurysms: results at initial (3–6-mo) follow-up. Neurosurgery 56:11911192, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Hayakawa M, , Murayama Y, , Duckwiler GR, , Gobin YP, , Guglielmi G, & Viñuela F: Natural history of the neck remnant of a cerebral aneurysm treated with the Guglielmi detachable coil system. J Neurosurg 93:561568, 2000

    • Search Google Scholar
    • Export Citation
  • 8

    Heran NS, , Song JK, , Kupersmith MJ, , Niimi Y, , Namba K, & Langer DJ, : Large ophthalmic segment aneurysms with anterior optic pathway compression: assessment of anatomical and visual outcomes after endosaccular coil therapy. J Neurosurg 106:968975, 2007

    • Search Google Scholar
    • Export Citation
  • 9

    Jennett B, & Bond M: Assessment of outcome after severe brain damage. Lancet 1:480484, 1975

  • 10

    Khanna RK, , Malik GM, & Qureshi N: Predicting outcome following surgical treatment of unruptured intracranial aneurysms: a proposed grading system. J Neurosurg 84:4954, 1996

    • Search Google Scholar
    • Export Citation
  • 11

    Lawton MT, , Raudzens PA, , Zabramski JM, & Spetzler RF: Hypothermic circulatory arrest in neurovascular surgery: evolving indications and predictors of patient outcome. Neurosurgery 43:1011, 1998

    • Search Google Scholar
    • Export Citation
  • 12

    Li MH, , Li YD, , Fang C, , Gu BX, , Cheng YS, & Wang YL, : Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases. Neuroradiology 49:819828, 2007

    • Search Google Scholar
    • Export Citation
  • 13

    Lownie SP, , Drake CG, , Peerless SJ, , Ferguson GG, & Pelz DM: Clinical presentation and management of giant anterior communicating artery region aneurysms. J Neurosurg 92:267277, 2000

    • Search Google Scholar
    • Export Citation
  • 14

    Mack WJ, , Ducruet AF, , Angevine PD, , Komotar RJ, , Shrebnick DB, & Edwards NM, : Deep hypothermic circulatory arrest for complex cerebral aneurysms: lessons learned. Neurosurgery 60:815827, 2007

    • Search Google Scholar
    • Export Citation
  • 15

    Malisch TW, , Guglielmi G, , Viñuela F, , Duckwiler G, , Gobin YP, & Martin NA, : Intracranial aneurysms treated with the Guglielmi detachable coil: midterm clinical results in a consecutive series of 100 patients. J Neurosurg 87:176183, 1997

    • Search Google Scholar
    • Export Citation
  • 16

    Molyneux A, , Kerr R, , Stratton I, , Sandercock P, , Clarke M, & Shrimpton J, : International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:12671274, 2002

    • Search Google Scholar
    • Export Citation
  • 17

    Popadiæ A, , Witzmann A, , Amann T, , Doringer W, , Fleisch M, & Häfel C, : The value of intraoperative angiography in surgery of intracranial aneurysms: a prospective study in 126 patients. Neuroradiology 43:466471, 2001

    • Search Google Scholar
    • Export Citation
  • 18

    Rooij WJ, & Sluzewski M: Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms. AJNR Am J Neuroradiol 27:16781680, 2006

    • Search Google Scholar
    • Export Citation
  • 19

    Solomon RA, , Fink ME, & Pile-Spellman J: Surgical management of unruptured intracranial aneurysms. J Neurosurg 80:440446, 1994

  • 20

    Sundt TM Jr, , Kobayashi S, , Fode NC, & Whisnant JP: Results and complications of surgical management of 809 intracranial aneurysms in 722 cases. Related and unrelated to grade of patient, type of aneurysm, and timing of surgery. J Neurosurg 56:753765, 1982

    • Search Google Scholar
    • Export Citation
  • 21

    Wiebers DO, , Whisnant JP, , Huston J III, , Meissner I, , Brown RD Jr, & Piepgras DG, : Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103110, 2003

    • Search Google Scholar
    • Export Citation
  • 22

    Wrobel CJ, , Meltzer H, , Lamond R, & Alksne JF: Intraoperative assessment of aneurysm clip placement by intravenous fluorescein angiography. Neurosurgery 35:970973, 1994

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 365 156 9
Full Text Views 206 20 1
PDF Downloads 122 8 0
EPUB Downloads 0 0 0