Multiple intracranial aneurysms: the role for simultaneous open microsurgical treatment

Intracranial aneurysms (IAs) occur in up to 6% of adults, with multiple IAs (MIAs), which are associated with higher clinical risks, occurring in up to one-third of this population. Treatment for MIAs includes open surgical, endovascular, or hybrid techniques. When possible, occlusion of MIAs with a single treatment is ideal. The authors examined the outcomes of single-stage microsurgical treatment of MIAs at their institution as an update to the literature in the endovascular era.

The authors undertook a retrospective review of the medical records of consecutive patients undergoing single-stage microsurgical treatment of MIAs between January 2014 and May 2024 at a single institution. Patient, aneurysm, treatment, and outcome data were collected.

Fifty-two patients with MIAs (44/52 [84.6%] female, mean age 58.60 ± 9.44 years, mean BMI 30.09 ± 7.76) were included: 39 patients had 2 aneurysms and 13 patients had 3 aneurysms. Of these patients, 30.8% (16/52) presented with aneurysmal subarachnoid hemorrhage (aSAH). Most aneurysms (112/117 [95.7%]) were in the anterior circulation, but 5 (4.3%) were in the posterior circulation. Most aneurysms were saccular (95.7%), and the mean maximal aneurysm dimension was 4.82 ± 2.55 mm. A single craniotomy was used in 50 of 52 (96.2%) patients, but a second craniotomy was required in 2 patients. All IAs were treated with clipping alone. Patients with aSAH had longer hospital and intensive care unit stays than those without aSAH (both p < 0.001). Two patients without aSAH and 4 patients with aSAH experienced vasospasm-related strokes. No other patients experienced postoperative ischemia. Over a mean follow-up of 17.4 ± 20.4 months, 51 of 52 (98.1%) patients had complete aneurysm occlusion, with 1 patient having a small stable neck residual. On follow-up, 50 of 52 (96.2%) patients were functionally independent (modified Rankin Scale score ≤ 2).

Open microsurgery is generally efficacious and safe for the simultaneous treatment of MIAs in appropriately selected patients with and without aSAH.