Consideration on strategy selection for cerebral aneurysms between direct surgery and endovascular therapy in stent assisted coil embolization era

Recent progress in the neuroendovascular treatment of cerebral aneurysms is remarkable. In particular, the introduction of vascular stents for neck-bridge has enabled treatment for complex aneurysms such as wide neck, large/giant and fusiform aneurysms. On the other hand, surgical neck clipping is technically well established, gold-standard treatment. In our paper, we cover accessibility, neck management and parent artery preservation, perforator problems, curability for large/giant aneurysms particularly for intraluminal thrombosis, and the neurological symptoms caused by mass effect according to each aneurysm’s, anatomic profile. Finally, we discuss the problems faced and the future outlook in applying direct surgery and endovascular treatment for formidable cerebral aneurysms.