Treatment of Intracranial Aneurysms

1. General Considerations

Definitive treatment of intracranial aneurysms is aimed at excluding the aneurysm from the cerebral circulation with preservation of the parent artery. Exclusion of the aneurysm from the cerebral circulation, by means of clip placement across the aneurysm neck surgically or with the placement of GDCs endovascularly, theoretically eliminates the risk of future rupture and its associated disability. Alternatively, small intracranial aneurysms, in select locations such as the cavernous sinus, may be observed with caution. Treatment of complications associated with aneurysmal SAH, such as seizures, cerebral vasospasm, and hydrocephalus, is also executed as necessary.

2. Microsurgery

Surgical clipping of intracranial aneurysms remains the definitive treatment and is well validated with proven long-term efficacy (Fig. 11). In experienced hands, aided by the operating microscope, microinstruments, and microsurgical principles, aneurysm clipping carries relatively low morbidity and mortality directly attributable to surgery. Aneurysms by virtue of their size, anatomical configuration, or location not easily amenable to standard techniques may require specialized adjuncts, including hypothermic circulatory arrest and vascular bypass grafts. Additionally, occlusion of the parent vessel with surgical or endo-vascular technology may be necessary, with or without concomitant bypass grafting, when clipping cannot be implemented.

The timing of surgery for ruptured intracranial aneurysms remains a matter of controversy. There is general consensus that "good-grade" patients (HuntHess grades 1-3) should undergo early surgery (within the first 48-72 hr) because recurrent hemorrhage is the major cause of death in patients who survive the initial hemorrhage. For "poor-grade" patients and those who are otherwise medically unstable or who bled several days earlier and are experiencing symptomatic vasospasm, surgery is delayed until the patients are stabilized and deemed capable of making a meaningful recovery (or until 10-14 days posthemorrhage in patients experiencing significant vasospasm). However, some centers have advocated early surgery in poor-grade patients and have achieved reasonable results. Some of these patients deemed to be too unstable for surgery may undergo early endovascular treatment.

3. Endovascular Therapy

The 1990s were characterized by the rapid emergence and refinement of endovascular techniques as a minimally invasive means of treating intracranial aneurysms. Endovascular placement of GDCs has been demonstrated to be a safe treatment modality for select patients. Currently, endovascular treatment is utilized predominantly for patients thought to be poor surgical candidates and for aneurysms anticipated to be difficult to treat surgically. GDCs evoke thrombosis within the aneurysmal sac, thereby isolating it from the circulation. Recently, placement of coils concomitant-ly with intracranial stents to facilitate satisfactory packing and to prevent migration of the coils has been described. Currently, long-term validation of endo-vascular treatment is not available. With design and implementation of new endovascular techniques and as long-term validation emerges, endovascular therapy is predicted to become an increasingly important treatment modality.

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