Surgical management of giant aneurysms

The proper management and treatment of giant intracranial aneurysms require meticulous preoperative and intraoperative planning. The dismal natural history of these lesions necessitates intervention; however, anatomic complexity and the technical difficulty associated with treatment make giant intracranial aneurysms one of the more challenging lesions a neurosurgeon can address. The basic tenants of aneurysm surgery apply to these lesions. Vascular control is crucial and may include measures as drastic as hypothermic circulatory arrest. Wide access with minimal retraction is highly desirable, and selection of the appropriate skull base approach is necessary to achieve this goal. Because the risk of aneurysm rupture is only truly eliminated if the lesion is fully excluded from the circulation, all intraoperative techniques must achieve this goal. If direct clipping of the aneurysm and reconstruction of the vessel lumen are impossible, other techniques, including parent-vessel ligation, aneurysm trapping, and bypass procedures, are important adjuvants in the neurosurgeon's arsenal. This article focuses on the skull base approaches and operative techniques that are essential to giant intracranial aneurysm surgery.