Surgical treatment of complex intracranial aneurysms.

Complex intracranial aneurysms include not only giant aneurysms (classically larger than 25 mm in diameter) but also smaller aneurysms in difficult locations of the human brain and cranial base. Such lesions are associated with a high risk of subarachnoid hemorrhage and progressive neurological deterioration or death caused by mass effect or stroke. In the past 30 years, the understanding and treatment of these lesions have progressed considerably. Nonetheless, a deep understanding of these lesions, including the nuances of blood flow dynamics, natural history, and potential therapeutic options, is necessary when one is managing such aneurysms. The senior author's (RFS) clinical experience with more than 5000 brain aneurysms was reviewed. We also reviewed recent literature on the surgical management of giant cerebral aneurysms, focusing on the most up-to-date microsurgical techniques. Combinations of therapies can be used in an attempt to provide a solution to various clinical dilemmas associated with the management of these difficult lesions. The synergistic association between microsurgery and endovascular modalities is also illustrated. On the basis of the knowledge obtained over the years, indirect and multimodality approaches are becoming more common as neurosurgeons strive to improve patient outcomes.