Challenges in the endovascular treatment of giant intracranial aneurysms.

OBJECTIVE: Giant intracranial aneurysms present unique therapeutic intricacies. The purpose of this study was to evaluate the anatomic and hemodynamic characteristics of these lesions and the current endovascular and combined surgical and endovascular techniques available for their treatment.
METHODS: A review of the literature and the personal experiences of the authors with endovascular treatment of giant aneurysms are presented. This review included anatomic and hemodynamic features and analysis of the diverse endovascular techniques that have been reported for the management of these aneurysms.
RESULTS: Anatomic features that create particular challenges in the therapeutic approach of giant aneurysms include size, shape (saccular, fusiform, serpentine), neck dimensions, branch involvement, intraluminal thrombosis, and location. Hemodynamic characteristics that affect endovascular treatment are lateral or terminal aneurysm type of flow and embolic material placement (inflow versus outflow aneurysmal region). The current endovascular therapeutic approaches include parent artery occlusion, trapping, endosaccular embolization with or without adjunctive techniques such as balloon-assisted or stent placement, and combined surgical and endovascular approaches, mainly with surgical revascularization and endovascular occlusion.
CONCLUSION: Although there are a wide variety of endovascular therapeutic options for the treatment of giant intracranial aneurysms, none of the current techniques is completely successful and free of complications in the management of these complex lesions. A detailed and individualized analysis of each case in conjunction with sufficient understanding of the anatomy and hemodynamics of a particular aneurysm should guide the therapeutic decision. Further research advances will assist in elucidating the factors predisposing to genesis, progression, and aggressive clinical manifestations of these giant lesions.