The Evolution of Giant Intracranial Aneurysm Treatment—A Single-Institution Retrospective Review of 156 Patients

Background: Giant intracranial aneurysms (GIAs), defined as aneurysms exceeding 25 mm in diameter, represent one of the most formidable challenges in neurosurgery. Compared to smaller aneurysms, GIAs carry a higher risk of mass effect, thromboembolism, and hemorrhage due to increased pressure and wide necks resulting in poorer outcomes.

Methods: This study is a retrospective review highlighting one institution’s evolution in the treatment of giant intracranial aneurysms from the years 1988 to 2018. The study included 156 patients with GIAs > 25mm treated at the Barrow Neurological Institution in Phoenix, Arizona. In order to analyze how GIA treatment has evolved over the past three decades, the patients in this study were separated in three distinct groups: Period 1—1988 to 1995, Period 2—1995 to 2005, and Period 3—2005 to 2018. Each group contained 52 patients to have an equal distribution. Treatment methods and outcomes based on neurological deficits, complications, and modified Rankin’s scores (mRS) score changes were analyzed.

Results: Clip reconstruction remained the predominant method throughout the three periods with a range of 62 to 73%, though endovascular treatment showed a significantly increasing use ([Fig. 1]). Cardiac standstill had a significant difference in usage with a p-value of 0.002 among the three groups. The highest rate of cardiac standstill usage was in Period 2 with 30% of all cases using this method and no cases in Period 3.

In terms of outcomes, no significant difference between the three periods was found with CSF infection, CSF leak, seizure, stroke, vasospasm, or other complications. Although neurological deficits and incidence of rerupture were not statistically significant (p = 0.220 and 0.078, respectively), both did show a downward trend with each time period. The total length of stay decreased over the periods (p = 0.009) with the longest stay in Period 1 of 17.5 days and the shortest in Period 3 with 9.3 days. In addition, the number of additional open surgical procedures needed also declined (p = 0.042) at a steady rate among the periods.

The mRS score changes from pre- to posttreatment at discharge were significantly different throughout the time periods (p = 0.009, [Fig. 2])). Period 2 had the highest number of patients who experienced a worsening of mRS scores (52%). Period 3 had the most patients with improvement (38%) from baseline.

When looking at outcomes based on treatment type ([Fig. 3]), a significant difference was also found (0.011). Cardiac standstill had the highest number of worsened mRS scores (71%), whereas clip trapping and endovascular had the highest rate of improved scores (44 and 38%, respectively).

Conclusion: The evolution of GIAs has evolved over the past few decades with increasing use of endovascular treatment and a decreasing use of cardiac standstill use. Period 2 experienced poorer outcomes overall, likely due to high use of cardiac standstill. Overall, this study shows recent decades have shown shorter hospital stays, fever neurological complications, fewer additional operations and improved functional status, highlighting the significant progress in the management of GIAs.

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Artikel online veröffentlicht:
07. Februar 2025