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. 2024 May 23:4:102838.
doi: 10.1016/j.bas.2024.102838. eCollection 2024.

Microsurgical and endovascular treatment of large and giant aneurysms of the anterior circulation: A systematic review

Alejandra Mosteiro  1 , Leire Pedrosa  1   2 , Marta Codes  1 , Luís Reyes  1 , Mariano Werner  3 , Sergio Amaro  2   4 , Joaquim Enseñat  1   2 , Ana Rodríguez-Hernández  5 , Marlien Aalbers  6 , Jeroen Boogaarts  6 , Ramon Torné  1   2   3
Affiliations

Microsurgical and endovascular treatment of large and giant aneurysms of the anterior circulation: A systematic review

Alejandra Mosteiro et al. Brain Spine. .

Abstract

Introduction: Large and Giant intracranial aneurysms (LGIAs) have become the paradigm for which endovascular techniques do not provide satisfactory results. Yet, microsurgery is followed by non-negligible rates of morbimortality. This scenario may have changed since the introduction of flow-diversion devices.

Research question: Contemporary and standardised revision on microsurgical and endovascular results, with emphasis on anterior circulation LGIAs.

Materials and methods: A systematic literature search was conducted in two databases (PubMed and Embase) on treatment outcomes of LGIAs of the anterior circulation, after the introduction of flow-diverters 2008/01/01, till 2023/05/20. Small case series (<5 cases), series including >15% of posterior circulation aneurysms, and studies not reporting clinical and/or angiographic outcomes were excluded.

Results: 44 relevant studies (observational cohorts) were identified, including 2923 LGIAs predominantly from anterior circulation. Mean follow-up 22 (±20) months. 1494 (51%) LGIAs were treated endovascularly and 1427 (49%) microsurgically. According to the random effects model, pooled rates of favourable clinical outcomes were 85.8% (CI 95% 82.6-88.4), complete occlusion 69.4% (CI 95% 63.7-7.46), complications 19.6% (CI 95%16-23.9) and mortality 5.6% (CI 95% 4.4-7.1). Focusing on type of treatment, occlusion rates are higher with microsurgical (842/993, 85% vs 874/1,299, 67%), although good outcomes are slightly more frequent with endovascular (1045/1,135, 92% vs 1120/1,294, 87%).

Discussion and conclusions: According to contemporary data about occlusion rates, functional outcomes, and complications, primary or secondary treatment of LGIAs of the anterior circulation seems justified. Microsurgical occlusion rates are higher in LGIAs. An expert consensus on reporting complications and management strategies is warranted.

Keywords: Clip; Complete occlusion; Endovascular; Flow-diverter; Large giant intracranial aneurysms; Mortality; Surgery; Trap.

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Conflict of interest statement

The authors have no conflicts of interest regarding this article.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram for the systematic review on LGIAs of anterior circulation (2008–2020). From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372:n71. https://doi.org/10.1136/bmj.n71 For more information, visit: http://www.prisma-statement.org/.
Fig. 2
Fig. 2
Forest plot of the favourable clinical outcome after LGIAs treatment.
Fig. 3
Fig. 3
Forest plot of the complete occlusion achieved after LGIAs treatment.
Fig. 4
Fig. 4
Forest plot of the advent of complications after LGIAs treatment.
Fig. 5
Fig. 5
Forest plot of mortality after LGIAs treatment.
Fig. 6
Fig. 6
Risk of bias assessment. In each study, the risk of bias was assessed according to the ROBIN-I tool and represented as a “traffic light” plot of the domain-level judgements for each individual parameter.
See this image and copyright information in PMC

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