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Surgical decision-making for managing complex intracranial aneurysms.

Giuseppe Esposito1, Luca Regli

  • 1Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, Zurich, CH-8091, Switzerland, giuseppe.esposito@usz.ch.

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Surgical strategies for complex intracranial aneurysms, including direct clipping, trapping, and revascularization, are guided by detailed pre-operative and intra-operative assessments. These tailored approaches aim for aneurysm exclusion and blood flow preservation.

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Area of Science:

  • Neurosurgery
  • Vascular Neurology
  • Interventional Neuroradiology

Background:

  • Complex intracranial aneurysms pose significant therapeutic challenges, often not amenable to standard endovascular techniques.
  • Surgical intervention remains a primary treatment modality for these complex lesions.
  • Decision-making for surgical management requires careful consideration of multiple pre-operative and intra-operative factors.

Purpose of the Study:

  • To illustrate a systematic "surgical decision making" process for managing complex intracranial aneurysms.
  • To present surgical strategies including direct clip reconstruction, complete trapping, and partial trapping.
  • To highlight the role of cerebral revascularization as a temporary or definitive bypass in aneurysm treatment.

Main Methods:

  • Pre-operative neuroradiological assessment and intra-operative findings guide strategy selection.
  • Key determinants include aneurysm location, angioanatomy, neck width, thrombosis, calcification, and collateral circulation.
  • Surgical options evaluated: direct clip reconstruction, complete trapping (classic/variant), and partial trapping (proximal/distal occlusion).

Main Results:

  • Cerebral revascularization is employed as a protective or flow-replacement bypass when vessel occlusion is necessary.
  • Complete and partial trapping strategies, often combined with bypass surgery, aim for aneurysm exclusion and flow preservation.
  • A case series of seven patients with complex intracranial aneurysms (ICA, ACom, MCA, PICA) successfully treated with these modalities.

Conclusions:

  • The choice between complete and partial trapping depends on angioanatomical criteria, with complete trapping favored for immediate exclusion.
  • Partial trapping is valuable when perforators arise from the aneurysm or surgical inspection is risky.
  • Tailored surgical strategies, including revascularization, are crucial for successful management of complex intracranial aneurysms.