Endovascular treatment of large and giant aneurysms

Abstract

Very large and giant (> or =15 mm) cerebral aneurysms have a poor natural history, with high risk of subarachnoid hemorrhage or progressive symptoms of mass effect. Several endovascular techniques may be applied for treatment, depending on location, size, anatomy and presence of collateral circulation. The authors reviewed their clinical experience in endovascular treatment of 232 very large and giant aneurysms and present their perspective on the present state of the art in endovascular therapy for these aneurysms.

Fig 1.

A 46-year-old woman with a coiled ruptured basilar tip aneurysm and an additional large fusiform middle cerebral artery aneurysm. A, Fusiform middle cerebral artery aneurysm on the M1-M2 transition. B, Angiogram after construction of an intracranial high-flow bypass from the supraclinoid internal carotid artery to the M2. The aneurysm has completely thrombosed.

Fig 2.

A 52-year-old man presenting with frontal syndrome. A, MR imaging reveals a partially thrombosed anterior communicating artery aneurysm with surrounding edema. B and C, Angiogram showing aneurysmal lumen and coil mesh after coiling. D and E, MR imaging (D) and angiogram (E) 8 years and 4 coiling procedures later: the aneurysm has enlarged with increased mass effect and edema. There is progressive frontal syndrome. F, Radiograph after fifth coiling. Note migration of previous coils into intraluminal thrombus. During 5 coiling procedures, 2970 cm of 0.018 coils were inserted.

Fig 3.

A 44-year-old woman with coiled ruptured basilar tip aneurysm with repeated reopening and progressive growth during 6 years’ time. Upper-row images show basilar tip aneurysm at presentation and before second, third, and fourth coiling at 1, 3, and 6 years. Middle-row images show corresponding results of coiling procedures, and lower-row images demonstrate increased mass effect on the brain stem at corresponding intervals. The patient is still asymptomatic.

Fig 4.

A 38-year-old man with ruptured basilar tip aneurysm with late regrowth and recurrent hemorrhage. A and B, Angiogram 8 years after first coiling demonstrates reopening at the neck that had slowly progressed during the years. Additional treatment was judged difficult. C, Angiogram after recurrent hemorrhage 10 years after first coiling. Note rapid enlargement and reopening of the aneurysm in the 8- to 10-year interval. The aneurysm was additionally coiled, and the patient made an uneventful recovery.