Clinical Presentation and Treatment Options for Giant Aneurysms: A Case Series in a Low/Middle-Income Setting

Introduction: Giant intracranial aneurysms (GIAs), although a rare occurrence (3–5%) has always been a surgical challenge with high morbimortality in neurosurgery. Although endovascular procedures have become an asset in tackling the issue, it comes with limitations, especially those related to financial resources. In low/middle-income countries, endovascular procedures may not be readily available for emergencies or the patient may be subject to long waits and potentially risky hospital transfers, making surgical management imperative.

Objectives: This study was aimed to compare the procedures, clinical manifestations, and therapeutic approaches involving GIAs in the, in a low/middle-income country setting to what is currently found in international literature.

Methods: In a single-center retrospective review, we analyzed all aneurysm cases from October 2012 to March 2018 and included those that met the criteria of diameter equal to or larger than 2.5 cm (thus being considered GIAs).

Results: A total of 190 IAs were operated, of which 8 (4.21%) were GIAs cases. The patients' age ranged from 48 to 73 years old, in a female-to-male ratio of 5:1. In terms of surgical approach, three were clipped, one had an extracranial–intracranial high flow bypass, one had thrombectomy with vascular reconstruction, and only one was transferred to another unit for endovascular treatment. The diameters were 3 with 2.5 to 3.5 cm, 4 with 3.5 to 4.5 cm, and 1 with more than 4.5 cm ([Fig. 1]). Patients' presentations varied as five presented with SAH only, two with visual deficits, and one with hemiparesis.

Conclusion: The treatment of GIAs remains challenging and requires individualized management. We concluded that our center has surgical volume, outcomes, epidemiologic aspects, and morbimortality similar to those found in current literature. Moreover, it is clear that, in low/middle-income scenarios, it is of utmost importance to train young surgeons in the surgical management of both advanced techniques, such as vascular reconstruction and bypass, as well as directly clipping of GIAs. Not only is it a feasible option in most cases, but it may be the only tactic available in these settings. In terms of surgical techniques, most cases were amenable to clipping only, not requiring complex combinations of techniques and, yet, yielding favorable results.

Illustrative Case:

Case 1: A 56-year-old female patient, presenting with left hemiparesis.

CT angiogram showing giant aneurysm (right MCA) + thrombus

Intraoperative images show dissection of the aneurysm neck. This aneurysm was not amenable to clipping and vessel reconstruction with multiple fenestrated clips.

Intraoperative image showing vessel reconstruction with fenestrated clips.

Fig. 1 Pie chart showing aneurysm size distribution.

Publication History

Article published online:
12 February 2021