Current Treatment Strategies for Intracranial Aneurysms: An Overview

Abstract

Intracranial aneurysm is a leading cause of stroke. Its treatment has evolved over the past 2 decades. This review summarizes the treatment strategies for intracranial aneurysms from 3 different perspectives: open surgery approach, transluminal treatment approach, and new technologies being used or trialed. We introduce most of the available treatment techniques in detail, including contralateral clipping, wrapping and clipping, double catheters assisting coiling and waffle-cone technique, and so on. Data from major trials such as Analysis of Treatment by Endovascular approach of Non-ruptured Aneurysms (ATENA), Internal Subarachnoid Trial (ISAT), Clinical and Anatomical Results in the Treatment of Ruptured Intracranial Aneurysms (CLARITY), and Barrow Ruptured Aneurysm Trial (BRAT) as well as information from other clinical reports and local experience are reviewed to suggest a clinical pathway for treating different types of intracranial aneurysms. It will be a valuable supplement to the current existing guidelines. We hope it could help assisting real-time decision-making in clinical practices and also encourage advancements in managing the disease.

Keywords: angiography; cerebral revascularization; intracranial aneurysm; intracranial vasospasm; stenting; stroke.

Figure 1.

Types of IAs: (A) saccular IA, (B) microaneurysm, (C) GIA, and (D) fusiform IA. IAs indicates intracranial aneurysms; GIA, giant IAs.

Figure 2.

Schematic figure of dissecting aneurysm in VA. VA indicates vertebral artery.

Figure 3.

Intraoperation ICGVA images before and after clipping (upper: microscopic visualization; lower: infrared view of blood flow using ICGVA), A, MCA IA prior to clipping. B, MCA IA postclipping. ICGVA indicates microscope-integrated near-infrared indocyanine green video angiography; MCA, middle cerebral artery; IA, intracranial aneurysm.

Figure 4.

Schematic diagram of STA-IC bypass. STA-IC indicates superficial temporal artery to an intracranial artery.

Figure 5.

Schematic diagram of BAC (A) and stent jail techniques (B) for wide-necked IAs. BAC indicates balloon-assisted coiling; IAs intracranial aneurysms.

Figure 6.

Schematic diagrams of special SAC techniques. A, stent jack: (A1) self-expandable stent navigated across the aneurysmal neck and microcatheter into the aneurysmal sac; (A2) first coil deployed; (A3) Stent deployed fully (or partially) bridging the neck, pushing the coil into the sac. B, Y-stenting: (B1) microcatheter navigated into the aneurysmal sac while 2 Neuroform stents navigated through the BA and respective PCA via exchange wires; (B2) 1 stent deployed; (B3) contralateral stent deployed in a “kissing” fashion. C, Waffle-cone technique: (C1) Enterprise stent and exchange-wire positioned; (C2) stent deployed; (C3) microcatheter positioned, coils deployed in waffle-cone configuration. SAC indicates stent-assisted coiling; BA, basilar artery; PCA; posterior cerebral artery.

Figure 7.

Schematic diagram of treatment strategies for fusiform IAs. (A) hemodynamics within a fusiform IA; (B) SAC for fusiform IA; (C) braided mesh stent for fusiform IA; and (D) covered stent for fusiform IA. IAs indicates intracranial aneurysms; SAC, stent-assisted coiling.

Figure 8.

A suggested clinical pathway for unruptured IAs. IAs indicates intracranial aneurysms.