Giant intracranial aneurysms (GIAs), which are defined as intracranial aneurysms (IAs) with a diameter of ≥25 mm, are most likely associated with the highest treatment costs of all IAs.
Giant intracranial aneurysms, are rare and heterogeneous lesions with complex vascular anatomy.
In 125 patients with 129 giant aneurysms (≥25 mm) who were treated between 1987 and 2007 at the Department of Neurosurgery of Helsinki University Central Hospital (HUCH). All the imaging studies and medical records were reviewed for relevant information.
The distribution of the giant aneurysms among regions was as follows: internal carotid artery (ICA) 39 %, middle cerebral artery (MCA) 32 %, vertebrobasilar and posterior cerebral artery (VB-PCA) region 25 %, and anterior cerebral artery (ACA) including the anterior communicating artery 5 %. The cavernous ICA segment (n = 21, 16 %) and the MCA bifurcation (n = 25, 19 %) were the most frequent specific locations. Half (n = 11) of all fusiform aneurysms were found in the VB-PCA region. As many as 41 % of the giant MCA aneurysms were ruptured. Major anatomic variations were found in three (2 %) and multiple giant aneurysms in three (2 %) patients. Wall calcification was noted in 24 % and intraluminal thrombosis in 33 % of ruptured giant aneurysms (n = 42).
The majority of giant aneurysms are located in the ICA and MCA regions, while the ACA region is an exceptional site. The MCA region is the most common site for ruptured giant aneurysms. Associated anatomic variations and the multiplicity of giant aneurysms are a rare finding 1).
Intracranial aneurysms (IA) are usually quantified according to their largest diameter. However, volumetry has recently been increasingly conducted as well, especially in giant intracranial aneurysms (GIAs). Since so far the true value of GIA volumetry is unknown
Magnetic resonance imaging of 69 unruptured GIAs in 66 patients was retrospectively evaluated. The largest diameter and volume were measured. Also, potential associations to the patients' clinical conditions were examined.
Comparing GIA sizes produced different results depending on whether GIA diameter or volume was measured. Measuring the diameter identified posterior circulation GIAs as the largest ones (39.2 mm, IQR 37.3-48.3), while measuring the volume found GIAs of the MCA to be the largest ones (12.3 cm(3), IQR 7.2-27.8). A correlation of GIA diameter and volume was only found in anterior circulation GIAs, which were predominantly saccular in shape, but not in those of the posterior circulation, of which most were fusiform. Neither GIA diameter nor GIA volume but only GIA location was associated with neurological deficits.
Diameter and volume measurements are not interchangeable modes of GIA quantification. This data suggest that the idea of distinguishing different sizes of GIA may be clinically less relevant than examining their location, shape or mass effect 2).
Endovascular GIA treatment produced higher direct costs than surgical GIA treatment mainly due to higher implant costs. Reducing endovascular implant costs may be the most effective tool to decrease direct costs of GIA treatment 4).
Surgical strategies other that direct clipping for the treatment of anterior circulation GIA lead to a significant decrease in GIA volume over time. The resulting decrease in mass effect was more sensitively monitored by the measurement of changes in ipsilateral LVV than changes in MLS. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov . Unique identifier: NCT02066493 5).
Giant Intracranial Aneurysm Yves Keravel