Surgical strategies for treatment of giant or large intracranial aneurysms: Our experiences with 123 cases

Giant or large intracranial aneurysms are the vascular surgeons greatest challenge. At our department, we have treated one hundred and twenty three patients with giant or large intracranial aneurysms between 1975 and 2003. These included 29 anterior circulation partially thrombosed giant aneurysms. 66 aneurysms were giant more than 2.5 cms and 57 were large aneurysms between 2 and 2.5 cms. With our experience in surgical treatment of these 123 cases, we find that the basic technique is trapping and evacuation and not just clipping of the aneurysm neck. Parent vessel reconstruction is the primary idea in giant or large aneurysms. Various technical skills need to be developed during the management of these difficult cases. These include clipping techniques like short time temporary clipping, tentative clipping, tandem clipping. The surgeon needs to be well versed with the various clips available like fenestrated clips, booster clips, dome clips etc. Many times thrombectomy, aneurysmectomy and vessel suturing procedures are required. It is equally necessary to have intraoperative confirmation by using either intraoperative DSA (digital subtraction angiography) or neuroendoscopy.