Introduction/purpose Giant intracranial aneurysms are defined as ≥2.5 cm in diameter. Currently, there are no standardized treatment guidelines for these aneurysms and their endovascular management remains challenging. We reviewed our aneurysm database in order to provide a better understanding of the demographics, clinical presentation, and various endovascular treatment modalities of these rare aneurysms.
Methods Institutional Review Board approval was obtained for this study. Retrospective review of our database containing 943 patients with aneurysm treatment between 2001–2015. Patient demographics, clinical presentation, aneurysm characteristics, treatment details, complications and outcomes based on follow-up imaging and clinical information was collected. Angiographic follow-up used MRA or DSA or both. Clinical outcome was evaluated at the last known clinical follow-up based on Glasgow outcome Score (GOS).
Results 33 patients (21 (62%) females, 13 (38%) males with 34 giant aneurysms were included. The mean age at presentation was 49 years (range, 15–75 years). 76% patients (n = 25) presented with seizures or cranial neuropathies from mass effect; 15% (n = 5) patients with hemorrhage and 9% (n = 3) had aneurysms discovered during evaluation for headaches. 76% (n = 26) aneurysms were in the anterior and 24% (n = 8) in the posterior circulation. Treatment modalities included parent vessel occlusion only (PVO) (N = 18; 53%), PVO + EC-IC bypass (PVO + bypass) (N = 5; 15%), coiling without PVO (N = 5; 15%), Pipeline stenting (N = 2; 6%), and stent-assisted coil embolization (N = 2; 6%). One patient was managed conservatively.
The median clinical follow-up (following the first aneurysm treatment procedure) was 8.5 months (mean 28.7 months, SD 39.5 months). All patients treated with PVO (n = 18; 17 unruptured and 1 ruptured) had prior successful balloon test occlusion of the parent artery. 89% of patients with PVO (n = 16) had Glasgow Outcome Scale (GOS) scores of 5 (excellent); the remaining two patients (unruptured) had a mean GOS score of 3.5. All patients treated with PVO had eventual complete aneurysmal thrombosis/occlusion, did not require any additional treatments, and did not experience distal embolic events. Five patients (all unruptured aneurysms) with failed balloon test occlusion were treated via PVO + bypass. The clinical outcomes in this group of patients were excellent, with a mean GOS of 4.8. Five patients (4 ruptured, 1 unruptured) were treated with aneurysm coil embolization without PVO. All required additional treatment modalities in order to treat recanalization, or had an unsuccessful initial procedure. Pipeline stenting was successful in the 2 patients (both unruptured aneurysms) it was performed, including a 3.0 cm fusiform aneurysm of the cavernous internal carotid artery.
Conclusions Parent vessel occlusion (PVO) is a safe and effective treatment option for intracranial giant aneurysms in patients with successful balloon test occlusion or extracranial - intracranial bypass. Flow diversion is promising but still evolving. In contradistinction, coil embolization with parent vessel preservation has high recurrence rate.
Disclosures S. Boddu: None. D. Kimball: None. M. Crimmins: None. A. Banihashemi: None. J. Knopman: None. A. Patsalides: None. P. Gobin: None.
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