Giant intracranial aneurysm surgery: the role of microvascular reconstruction.

The surgical management of 62 anterior circulation giant intracranial aneurysms is presented. Women were affected three times as frequently as men. Thirty-two patients presented with local mass effect, which was the most common mode of presentation, while 26 patients had subarachnoid hemorrhage. Three patients presented with transient ischemic attacks and three patients presented with seizures. In 16 cases the giant intracranial aneurysm involved the cavernous sinus and indirect surgery was performed. Ten patients were treated with extracranial-intracranial bypass and gradual occlusion of the proximal internal carotid artery. Six patients were treated with extracranial-intracranial bypass and trapping of the aneurysm (sudden occlusion of internal carotid artery). Sudden occlusion was poorly tolerated, and 50% of the patients developed ischemic complications. In 46 cases of giant intracranial aneurysm without involvement of the cavernous sinus, direct surgery was undertaken. In 31 patients the aneurysm could be clipped without compromise to the surrounding vessels. In 15 patients there was compromise of surrounding vessels or the aneurysm sac was excised and so microvascular reconstruction was needed. Local intracranial reconstruction was preferred whenever feasible. The results of patients who needed reconstruction were similar to those who did not need reconstruction. Overall, 84% of patients had an excellent or good outcome after surgery. The mortality was 5%.