Giant and Very Large Intracranial Aneurysms: Surgical Strategies and Special Issues

  • Sabino Luzzi
  • Massimo Gallieni
  • Mattia Del Maestro
  • Donatella Trovarelli
  • Alessandro Ricci
  • Renato Galzio
Conference paper
Part of the Acta Neurochirurgica Supplement book series (NEUROCHIRURGICA, volume 129)


Giant intracranial aneurysms (GIAs) and very large intracranial aneurysms (VLAs) have a poor natural history because of a high incidence of bleeding and strokes. These lesions always represent a great challenge for neurosurgeons and interventional neuroradiologists because of some peculiar intrinsic features such as size, angioarchitecture, wide neck, mass effect, intraluminal thrombosis, atherosclerotic changes, involvement of branches and perforators, and a frequent need to perform revascularization procedures. The results of a cumulative surgical series of 75 VLAs and GIAs are reported. Thirty-three aneurysms were unruptured. Sixty aneurysms underwent direct surgical treatment consisting of 56 direct clippings, 3 trappings w/o revascularization, and 1 wrapping. Fifteen aneurysms were treated by means of extracranial to intracranial (EC-IC) high-flow bypass. An mRS score ranging between 0 and 2 was observed in 54 patients, whereas an mRS of 3 was seen in 5 patients. Four patients had a severe disability (mRS 4–5) and six patients died. Aneurysm’s fragmentation, with stacking and seating clips, thrombectomy, and aneurysmorrhaphy were the techniques most frequently employed. Revascularization options involving EC-IC high-flow bypass were used in cases not amenable for direct treatment. Some technical tips and special issues related to the surgical management of these complex lesions are discussed.


Intracranial aneurysms Giant intracranial aneurysms Clipping By-pass surgery Revascularization techniques Subarachnoid hemorrhage 


Conflict of Interest Statement

The authors declare that they have no conflict of interest.


  1. 1.
    Barth A, de Tribolet N. Growth of small saccular aneurysms to giant aneurysms: presentation of three cases. Surg Neurol. 1994;41(4):277–80.CrossRefGoogle Scholar
  2. 2.
    Krings T, Piske RL, Lasjaunias PL. Intracranial arterial aneurysm vasculopathies: targeting the outer vessel wall. Neuroradiology. 2005;47(12):931–7.CrossRefGoogle Scholar
  3. 3.
    Barrow DL, Alleyne C. Natural history of giant intracranial aneurysms and indications for intervention. Clin Neurosurg. 1995;42:214–44.PubMedGoogle Scholar
  4. 4.
    International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. N Engl J Med. 1998;339(24):1725–33.CrossRefGoogle Scholar
  5. 5.
    Drake CG. Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg. 1979;26:12–95.CrossRefGoogle Scholar
  6. 6.
    Hosobuchi Y. Direct surgical treatment of giant intracranial aneurysms. J Neurosurg. 1979;51(6):743–56.CrossRefGoogle Scholar
  7. 7.
    Lawton MT, Spetzler RF. Surgical management of giant intracranial aneurysms: experience with 171 patients. Clin Neurosurg. 1995;42:245–66.PubMedGoogle Scholar
  8. 8.
    Lawton MT, Spetzler RF. Surgical strategies for giant intracranial aneurysms. Neurosurg Clin N Am. 1998;9(4):725–42.CrossRefGoogle Scholar
  9. 9.
    Sekhar LN, Tariq F, Mai JC, Kim LJ, Ghodke B, Hallam DK, Bulsara KR. Unyielding progress: treatment paradigms for giant aneurysms. Clin Neurosurg. 2012;59:6–21.CrossRefGoogle Scholar
  10. 10.
    Sousa A, Sousa Filho J, Dellaretti Filho M. Treatment of giant intracranial aneurysms: a review based on experience from 286 cases. Arq Bras Neurocir. 2015;34(4):295–303.CrossRefGoogle Scholar
  11. 11.
    Spetzler RF, Schuster H, Roski RA. Elective extracranial-intracranial arterial bypass in the treatment of inoperable giant aneurysms of the internal carotid artery. J Neurosurg. 1980;53(1):22–7.CrossRefGoogle Scholar
  12. 12.
    Sundt TM, Piepgras DG. Surgical approach to giant intracranial aneurysms. Operative experience with 80 cases. J Neurosurg. 1979;51(6):731–42.CrossRefGoogle Scholar
  13. 13.
    Symon L, Vajda J. Surgical experiences with giant intracranial aneurysms. J Neurosurg. 1984;61(6):1009–28.CrossRefGoogle Scholar
  14. 14.
    Jahromi BS, Mocco J, Bang JA, Gologorsky Y, Siddiqui AH, Horowitz MB, Hopkins LN, Levy EI. Clinical and angiographic outcome after endovascular management of giant intracranial aneurysms. Neurosurgery. 2008;63(4):662–74.CrossRefGoogle Scholar
  15. 15.
    Diaz FG, Ausman JI, Pearce JE. Ischemic complications after combined internal carotid artery occlusion and extracranial-intracranial anastomosis. Neurosurgery. 1982;10(5):563–70.CrossRefGoogle Scholar
  16. 16.
    Hacein-Bey L, Connolly ES, Duong H, Vang MC, Lazar RM, Marshall RS, Young WL, Solomon RA, Pile-Spellman J. Treatment of inoperable carotid aneurysms with endovascular carotid occlusion after extracranial-intracranial bypass surgery. Neurosurgery. 1997;41(6):1225–31.CrossRefGoogle Scholar
  17. 17.
    Heros RC. Thromboembolic complications after combined internal carotid ligation and extra- to-intracranial bypass. Surg Neurol. 1984;21(1):75–9.CrossRefGoogle Scholar
  18. 18.
    Heros RC, Nelson PB, Ojemann RG, Crowell RM, DeBrun G. Large and giant paraclinoid aneurysms: surgical techniques, complications, and results. Neurosurgery. 1983;12(2):153–63.CrossRefGoogle Scholar
  19. 19.
    Ibrahim TF, Jahromi BR, Miettinen J, Raj R, Andrade-Barazarte H, Goehre F, Kivisaari R, Lehto H, Hernesniemi J. Long-term causes of death and excess mortality after carotid artery ligation. World Neurosurg. 2016;90:116–22.CrossRefGoogle Scholar
  20. 20.
    Niiro M, Shimozuru T, Nakamura K, Kadota K, Kuratsu J. Long-term follow-up study of patients with cavernous sinus aneurysm treated by proximal occlusion. Neurol Med Chir. 2000;40(2):88–96.CrossRefGoogle Scholar
  21. 21.
    Polevaya NV, Kalani MYS, Steinberg GK, Tse VCK. The transition from hunterian ligation to intracranial aneurysm clips: a historical perspective. Neurosurg Focus. 2006;20(6):E3.CrossRefGoogle Scholar
  22. 22.
    Steinberg GK, Drake CG, Peerless SJ. Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms. Immediate results and long-term outcome in 201 patients. J Neurosurg. 1993;79(2):161–73.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Sabino Luzzi
    • 1
  • Massimo Gallieni
    • 2
  • Mattia Del Maestro
    • 2
  • Donatella Trovarelli
    • 3
  • Alessandro Ricci
    • 1
  • Renato Galzio
    • 1
    • 2
  1. 1.Department of NeurosurgerySan Salvatore City HospitalL’AquilaItaly
  2. 2.Department of Life, Health and Environmental Sciences (MESVA)University of L’AquilaL’AquilaItaly
  3. 3.Department of AnesthesiologySan Salvatore City HospitalL’AquilaItaly

Personalised recommendations