Clinical Neurology and Neurosurgery 110 (2008) 674–681 Surgical management of giant intracranial aneurysms Bhawani Shankar Sharma a,∗ , Aditya Gupta a , Faiz Uddin Ahmad a , Ashish Suri a , Veer Singh Mehta b a Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi 110029, India b Paras Hospital, Sushant Lok, Gurgaon, Haryana, India Received 16 August 2007; received in revised form 29 March 2008; accepted 5 April 2008 Abstract Objectives: The natural history of giant intracranial aneurysms is generally morbid. Mortality and morbidity associated with giant aneurysms is also higher than for smaller aneurysms. This study was carried out to assess the demographic profile, presenting features, complications, and outcome after surgical treatment of giant intracranial aneurysms. Patients and methods: A retrospective review of the medical records of all patients with giant intracranial aneurysms treated in the Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, from January 1995 through June 2007 was performed. The demographic profiles, presenting features, radiological findings, surgical treatments, and outcomes were assessed. Results: A total of 1412 patients harboring 1675 aneurysms were treated. Out of these, 222 patients had 229 (13.7%) giant aneurysms, and of those, 181 aneurysms in 177 patients were managed surgically while 48 were treated with endovascular therapy. In the patients treated with surgery, common clinical presentations included subarachnoid hemorrhage (SAH) in 110 (62%) cases followed by mass effect in 57 (32%) cases. In patients who presented with SAH, the Hunt and Hess SAH grading was: grade I in 43 (39%), grade II in 40 (36%), grade III in 23 (21%), grade IV in two (2%), and grade V in 2 (2%) patients. One hundred and seven aneurysms (in 103 patients) were treated using direct surgical clipping. Forty-six patients with good collateral circulation were treated by gradual occlusion and ligation of the internal carotid artery (ICA) in the neck with a Silverstone clamp. Another nine patients with good collateral circulation, but persisting symptoms after ICA ligation, required trapping for obliteration of the aneurysm. Eleven patients with poor collateral circulation required extracranial–intracranial (EC–IC) bypass before proximal ICA ligation. A post-operative digital subtraction angiography (DSA) was performed in 118 patients and revealed well-obliterated aneurysm in 106 patients. The total treatment mortality rate was 9%. In the last 5 years, 117 patients were operated on with four operative deaths. Overall, the outcome was excellent in 131 (74.0%), good in 22 (12.4%), and poor in eight (4.5%) cases. Conclusions: It is concluded that 14% of all intracranial aneurysms are giant. The most common clinical presentation is SAH followed by features of an intracranial mass lesion. The cavernous ICA is the most common portion of the ICA affected. Direct surgical clipping is a safe and effective method of treatment and should be considered the first line of treatment whenever possible. With proper case selection, optimal radiological evaluation, and appropriate surgical strategy, it is possible to achieve a favorable outcome in almost 90% of the cases. © 2008 Elsevier B.V. All rights reserved. Keywords: Intracranial aneurysm; Giant; Surgery; Management; Subarachnoid hemorrhage 1. Introduction Intracranial aneurysms larger than 25 mm in maximum diameter are classified as giant [1]. The natural history of giant intracranial aneurysms (GIAs) is generally morbid as a result of hemorrhage, neural compression, and thromboem- bolic episodes. Left untreated, the majority of patients suffer ∗ Corresponding author. Tel.: +91 9868398232; fax: +91 11 26588641. E-mail address: drsharmabs@yahoo.com (B.S. Sharma). from ruptures of these aneurysms. Once ruptured, the cumu- lative frequency of rebleed at 14 days is 18.4%. It has been shown that mortality is above 60% within 2 years and 80% of patients with untreated symptomatic GIAs are dead or totally incapacitated within 5 years of diagnosis [2–4]. When an aneurysm grows to giant size, the neck widens and may incorporate the efferent arteries. The lumen usu- ally contains a thrombus and the wall may become calcified. All of these features alone or in combination preclude sim- ple surgical clipping. Endovascular treatment for GIAs is 0303-8467/$ – see front matter © 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2008.04.001