Italian cooperative study on giant intracranial aneurysms: 3. Modalities of treatment.

240 patients with giant aneurysms were treated in 10 Italian centres with various therapeutic modalities: out of them, 50 patients were conservatively treated (19 with a severe intracranial haemorrhage). Direct surgery was performed in 140 patients: 67% of patients with aneurysms between 2 and 2.5 cm (A 1 group) and 50% of patients with larger aneurysms (A 2 group). The aneurysm could be secured by clip in 102 cases (56% of A 1 and 31% of A 2 patients). In patients with subarachnoid haemorrhage, surgery was done within 3 days in 24 cases, between 4 and 14 days in 21 cases, and later in 52 cases. In patients operated on directly, brain swelling was observed in 39% of cases; controlled hypotension was employed in 56 cases, and temporary vessel occlusion (mainly of M 1 tract) in 33 cases; removal of intra-aneurysmal thrombi was done in 18 cases, and intraoperative aneurysmal rupture occurred in 39 cases. Carotid ligation was performed in 31 patients, and was associated with a by-pass in 17 cases. Balloon occlusion was performed in 23 cases, and was associated with a by-pass in 10 cases. As regards aneurysmal location, intracavernous aneurysms were treated mainly by balloon occlusion or carotid ligation, while carotid/ophthalmic, middle cerebral and anterior communicating aneurysms were treated prevalently by direct surgery. 60% of treated patients were submitted to postoperative angiography, and 54% to postoperative CT scan; total obliteration of the aneurysm was documented in 83% of patients submitted to postoperative angiography.