Giant or large
intracranial aneurysms are the vascular neurosurgeon's greatest challenge. At our department, we have treated one hundred and thirty nine patients with giant or large
intracranial aneurysms between 1975 and 2001. These included 37 partially thrombosed giant
aneurysms. 75
aneurysms were giant (> 2.5 cm) and 64 were large
aneurysms (2-2.5 cm). Three-dimensional computed tomography angiograms were performed in patients besides MRI angiography and digital subtraction angiography. These were found to be very valuable in the preoperative assessment of surgical anatomy of the
aneurysm with respect to the branch arteries and perforators origin besides knowing the relations to the skull base. With our experience in surgical treatment of these 139 cases, we find that the basic technique is trapping and evacuation and not just clipping of the
aneurysm neck but also reconstruction of the artery bearing the
aneurysm, especially with wide-necked
aneurysms. Use of multiple clipping, tandem clipping or dome clipping as per the intraoperative situation, is very helpful in dealing with giant
aneurysms as also is the use of different types of clips like fenestrated
clip with straight
clip (combination clipping), booster
clip, dome clips etc. While selecting surgical strategy for partially thrombosed giant
aneurysm, securing the neck is most important. If the neck is too narrow to reconstruct, aneurysmectomy with anastomosis is one of the surgical strategies. An extracranial intracranial bypass should be considered in cases where clipping or parent artery
ligation is expected to be associated with compromise of cerebral circulation.