{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,30]],"date-time":"2026-05-30T09:01:49Z","timestamp":1780131709819,"version":"3.54.0"},"reference-count":36,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,12,1]]},"abstract":"\n OBJECTIVE<\/jats:title>\n Giant intracranial aneurysms (GIAs; \u2265 25 mm) are a distinct subset of aneurysms with worse outcomes compared with other aneurysms. The aim of this review was to analyze patient and aneurysm-related factors that influenced management decisions, including the need for bypass procedures, and to assess outcomes, including morbidity and mortality, associated with the procedures.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n This retrospective analysis included patients with GIAs treated microsurgically at a single institution from 2010 to 2023. Aneurysms were classified by location as infraclinoidal internal carotid artery (ICA), supraclinoidal ICA, anterior cerebral artery (ACA), middle cerebral artery (MCA), and basilar artery. Techniques included direct clipping, bypass with trapping, and parent artery ligation. Preoperative imaging included CT, DSA, and balloon occlusion testing. Intraoperative adjuncts, such as indocyanine green video angiography and Doppler ultrasonography, ensured procedural efficacy. Outcomes were measured by the modified Rankin Scale (score \u2264 2 indicating good outcomes), aneurysm obliteration rates, and complication rates. Descriptive statistics were used to compare patients with ruptured versus unruptured aneurysms and those with anterior versus posterior circulation aneurysms.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n Among 77 patients (mean age 44.7 years) with GIAs included in the analysis, 20 had infraclinoidal ICA, 25 had supraclinoidal ICA, 10 had ACA, 20 had MCA, and 2 had basilar artery aneurysms. Sixty-one patients (79.2%) achieved good outcomes, with an overall 96.8% (61\/63) complete obliteration rate. Infraclinoidal ICA aneurysms had the lowest morbidity (10%), while supraclinoidal ICA aneurysms had 28% morbidity and 12% mortality. High-flow bypass procedures were required for 24.7% (19\/77) of patients. MCA and ACA aneurysms each had a 20% morbidity rate. Overall complications included infarcts (13%, 10\/77), persistent hemiparesis\/paraparesis (15.6%, 12\/77), and infections (1.3%, 1\/77). The surgical mortality rate was 5.2% (4\/77). Despite a higher proportion of ruptured GIAs (42%, 32\/77), this series demonstrated clinical equivalence in microsurgical results compared with contemporary series.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n Microsurgical management of GIAs is effective, with high obliteration rates and good outcomes in 79.2% of patients, particularly for anterior circulation aneurysms. Location-specific strategies delivered optimized results, with bypass procedures required in selected cases. Preoperative collateral flow assessment is critical. Despite endovascular advancements in the management of GIAs (which might need retreatment in 20% of patients), microsurgery had a complete occlusion rate of 96.8%, demonstrating superior durability. These findings underscore the role of microsurgery in GIAs, emphasizing tailored approaches to minimize risks.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2025.9.focus25699","type":"journal-article","created":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T13:25:38Z","timestamp":1764595538000},"page":"E10","source":"Crossref","is-referenced-by-count":1,"title":["Microsurgical management of giant intracranial aneurysms in the endovascular era"],"prefix":"10.3171","volume":"59","author":[{"given":"Srinivas","family":"Dwarakanath","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harsh","family":"Deora","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abhijit","family":"Goyal-Honavar","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abhinith","family":"Shashidhar","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arivazhagan","family":"Arimappamagan","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dhaval","family":"Shukla","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sampath","family":"Somanna","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"Trends in Cerebrovascular Surgery and Interventions","article-title":"Current strategies in the treatment of intracranial large and giant aneurysms","author":"Gmeiner M","year":"2021","unstructured":"Gmeiner M, Gruber ACurrent strategies in the treatment of intracranial large and giant aneurysms. In: Esposito G, Regli L, Cenzato M, Kaku Y, Tanaka M, Tsukahara T, eds.Trends in Cerebrovascular Surgery and Interventions. Springer;2021. Accessed October 17, 2025. http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK573764\/"},{"issue":"1","key":"b2","series-title":"Skull Base","first-page":"37","article-title":"Evaluation of the prognostic indicators of giant intracranial aneurysms","volume":"21","author":"Vannemreddy PSSV","year":"2011","unstructured":"Vannemreddy PSSV, Nourbakhsh A, Nanda AEvaluation of the prognostic indicators of giant intracranial aneurysms. Skull Base. 2011;21(1):37\u201346."},{"issue":"8","key":"b3","series-title":"Acta Neurochir (Wien)","first-page":"1621","article-title":"Mortality rates for giant aneurysms","volume":"153","author":"Hakma Z","year":"2011","unstructured":"Hakma Z, Ramaswamy R, Loftus CMMortality rates for giant aneurysms. Acta Neurochir (Wien). 2011;153(8):1621\u20131623."},{"issue":"24","key":"b4","series-title":"N Engl J Med","first-page":"1725","article-title":"Unruptured intracranial aneurysms\u2013risk of rupture and risks of surgical intervention","volume":"339","year":"1998","unstructured":"Unruptured intracranial aneurysms\u2013risk of rupture and risks of surgical intervention. N Engl J Med. 1998;339(24):1725\u20131733."},{"issue":"5","key":"b5","series-title":"J Neurosurg","first-page":"656","article-title":"Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation","volume":"81","author":"Drake CG","year":"1994","unstructured":"Drake CG, Peerless SJ, Ferguson GGHunterian proximal arterial occlusion for giant aneurysms of the carotid circulation. J Neurosurg. 1994;81(5):656\u2013665."},{"key":"b6","first-page":"42","article-title":"Surgical outcome of primary clipping for anterior circulation aneurysms of size 2 centimeters or larger","volume":"122","author":"Furtado SV","year":"2014","unstructured":"Furtado SV, Saikiran NA, Thakar S, Surgical outcome of primary clipping for anterior circulation aneurysms of size 2 centimeters or larger. Clin Neurol Neurosurg.2014;122:42\u201349."},{"issue":"3-4","key":"b7","series-title":"Cerebrovasc Dis","first-page":"187","article-title":"Outcome of surgical or endovascular treatment of giant intracranial aneurysms, with emphasis on age, aneurysm location, and unruptured aneuryms - a systematic review and meta-analysis","volume":"41","author":"Dengler J","year":"2016","unstructured":"Dengler J, Maldaner N, Gl\u00e4sker S, Outcome of surgical or endovascular treatment of giant intracranial aneurysms, with emphasis on age, aneurysm location, and unruptured aneuryms - a systematic review and meta-analysis. Cerebrovasc Dis. 2016;41(3-4):187\u2013198."},{"issue":"8","key":"b8","series-title":"J Clin Neurosci","first-page":"1424","article-title":"Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience","volume":"21","author":"Chalouhi N","year":"2014","unstructured":"Chalouhi N, Thakkar V, Tjoumakaris S, Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience. J Clin Neurosci. 2014;21(8):1424\u20131427."},{"issue":"7","key":"b9","series-title":"Clin Neurol Neurosurg","first-page":"674","article-title":"Surgical management of giant intracranial aneurysms","volume":"110","author":"Sharma BS","year":"2008","unstructured":"Sharma BS, Gupta A, Ahmad FU, Suri A, Mehta VSSurgical management of giant intracranial aneurysms. Clin Neurol Neurosurg. 2008;110(7):674\u2013681."},{"key":"b10","first-page":"100007","article-title":"A retrospective study in microsurgical procedures of large and giant intracranial aneurysms: an outcome analysis","volume":"2","author":"Balaji A","year":"2019","unstructured":"Balaji A, Rajagopal N, Yamada Y, Teranishi T, Kawase T, Kato YA retrospective study in microsurgical procedures of large and giant intracranial aneurysms: an outcome analysis. World Neurosurg X.2019;2:100007."},{"issue":"4","key":"b11","series-title":"Neurosurgery","first-page":"903","article-title":"Predictors of clinical and angiographic outcome after surgical or endovascular therapy of very large and giant intracranial aneurysms","volume":"68","author":"Darsaut TE","year":"2011","unstructured":"Darsaut TE, Darsaut NM, Chang SD, Predictors of clinical and angiographic outcome after surgical or endovascular therapy of very large and giant intracranial aneurysms. Neurosurgery. 2011;68(4):903\u2013916."},{"issue":"4","key":"b12","series-title":"Neurol India","first-page":"984","article-title":"Microsurgery of giant intracranial aneurysm: a single institution outcome study","volume":"69","author":"Misra B","year":"2021","unstructured":"Misra B, Warade A, Rohan R, Sarit SMicrosurgery of giant intracranial aneurysm: a single institution outcome study. Neurol India. 2021;69(4):984\u2013990."},{"issue":"6","key":"b13","series-title":"Neurosurgery","first-page":"1261","article-title":"Giant intracranial aneurysms: evolution of management in a contemporary surgical series","volume":"69","author":"Sughrue ME","year":"2011","unstructured":"Sughrue ME, Saloner D, Rayz VL, Lawton MTGiant intracranial aneurysms: evolution of management in a contemporary surgical series. Neurosurgery. 2011;69(6):1261\u20131271."},{"key":"b14","first-page":"293","article-title":"Giant intracranial aneurysms: surgical treatment and analysis of risk factors","volume":"102","author":"Xu L","year":"2017","unstructured":"Xu L, Deng X, Wang S, Giant intracranial aneurysms: surgical treatment and analysis of risk factors. World Neurosurg.2017;102:293\u2013300."},{"issue":"1","key":"b15","series-title":"Turk Neurosurg","first-page":"53","article-title":"Clipping of large and giant aneurysms of anterior circulation","volume":"21","author":"Kars HZ","year":"2011","unstructured":"Kars HZ, Gurelik MClipping of large and giant aneurysms of anterior circulation. Turk Neurosurg. 2011;21(1):53\u201358."},{"issue":"10","key":"b16","series-title":"Neuroradiology","first-page":"819","article-title":"Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases","volume":"49","author":"Li MH","year":"2007","unstructured":"Li MH, Li YD, Fang C, Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases. Neuroradiology. 2007;49(10):819\u2013828."},{"issue":"5-6","key":"b17","series-title":"World Neurosurg","first-page":"752","article-title":"Microsurgical management of giant intracranial aneurysms: a single surgeon experience from Louisiana State University, Shreveport","volume":"81","author":"Nanda A","year":"2014","unstructured":"Nanda A, Sonig A, Banerjee AD, Javalkar VKMicrosurgical management of giant intracranial aneurysms: a single surgeon experience from Louisiana State University, Shreveport. World Neurosurg. 2014;81(5-6):752\u2013764."},{"key":"b18","first-page":"e190","article-title":"Evaluation of microsurgery for managing giant or complex cerebral aneurysms: a retrospective study","volume":"115","author":"Ota N","year":"2018","unstructured":"Ota N, Matsukawa H, Noda K, Evaluation of microsurgery for managing giant or complex cerebral aneurysms: a retrospective study. World Neurosurg.2018;115:e190\u2013e199."},{"key":"b1","series-title":"Trends in Cerebrovascular Surgery and Interventions","article-title":"Current strategies in the treatment of intracranial large and giant aneurysms","author":"Gmeiner M","year":"2021","unstructured":"Gmeiner M, Gruber ACurrent strategies in the treatment of intracranial large and giant aneurysms. In: Esposito G, Regli L, Cenzato M, Kaku Y, Tanaka M, Tsukahara T, eds.Trends in Cerebrovascular Surgery and Interventions. Springer;2021. Accessed October 17, 2025. http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK573764\/"},{"issue":"1","key":"b2","series-title":"Skull Base","first-page":"37","article-title":"Evaluation of the prognostic indicators of giant intracranial aneurysms","volume":"21","author":"Vannemreddy PSSV","year":"2011","unstructured":"Vannemreddy PSSV, Nourbakhsh A, Nanda AEvaluation of the prognostic indicators of giant intracranial aneurysms. Skull Base. 2011;21(1):37\u201346."},{"issue":"8","key":"b3","series-title":"Acta Neurochir (Wien)","first-page":"1621","article-title":"Mortality rates for giant aneurysms","volume":"153","author":"Hakma Z","year":"2011","unstructured":"Hakma Z, Ramaswamy R, Loftus CMMortality rates for giant aneurysms. Acta Neurochir (Wien). 2011;153(8):1621\u20131623."},{"issue":"24","key":"b4","series-title":"N Engl J Med","first-page":"1725","article-title":"Unruptured intracranial aneurysms\u2013risk of rupture and risks of surgical intervention","volume":"339","year":"1998","unstructured":"Unruptured intracranial aneurysms\u2013risk of rupture and risks of surgical intervention. N Engl J Med. 1998;339(24):1725\u20131733."},{"issue":"5","key":"b5","series-title":"J Neurosurg","first-page":"656","article-title":"Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation","volume":"81","author":"Drake CG","year":"1994","unstructured":"Drake CG, Peerless SJ, Ferguson GGHunterian proximal arterial occlusion for giant aneurysms of the carotid circulation. J Neurosurg. 1994;81(5):656\u2013665."},{"key":"b6","first-page":"42","article-title":"Surgical outcome of primary clipping for anterior circulation aneurysms of size 2 centimeters or larger","volume":"122","author":"Furtado SV","year":"2014","unstructured":"Furtado SV, Saikiran NA, Thakar S, Surgical outcome of primary clipping for anterior circulation aneurysms of size 2 centimeters or larger. Clin Neurol Neurosurg.2014;122:42\u201349."},{"issue":"3-4","key":"b7","series-title":"Cerebrovasc Dis","first-page":"187","article-title":"Outcome of surgical or endovascular treatment of giant intracranial aneurysms, with emphasis on age, aneurysm location, and unruptured aneuryms - a systematic review and meta-analysis","volume":"41","author":"Dengler J","year":"2016","unstructured":"Dengler J, Maldaner N, Gl\u00e4sker S, Outcome of surgical or endovascular treatment of giant intracranial aneurysms, with emphasis on age, aneurysm location, and unruptured aneuryms - a systematic review and meta-analysis. Cerebrovasc Dis. 2016;41(3-4):187\u2013198."},{"issue":"8","key":"b8","series-title":"J Clin Neurosci","first-page":"1424","article-title":"Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience","volume":"21","author":"Chalouhi N","year":"2014","unstructured":"Chalouhi N, Thakkar V, Tjoumakaris S, Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience. J Clin Neurosci. 2014;21(8):1424\u20131427."},{"issue":"7","key":"b9","series-title":"Clin Neurol Neurosurg","first-page":"674","article-title":"Surgical management of giant intracranial aneurysms","volume":"110","author":"Sharma BS","year":"2008","unstructured":"Sharma BS, Gupta A, Ahmad FU, Suri A, Mehta VSSurgical management of giant intracranial aneurysms. Clin Neurol Neurosurg. 2008;110(7):674\u2013681."},{"key":"b10","first-page":"100007","article-title":"A retrospective study in microsurgical procedures of large and giant intracranial aneurysms: an outcome analysis","volume":"2","author":"Balaji A","year":"2019","unstructured":"Balaji A, Rajagopal N, Yamada Y, Teranishi T, Kawase T, Kato YA retrospective study in microsurgical procedures of large and giant intracranial aneurysms: an outcome analysis. World Neurosurg X.2019;2:100007."},{"issue":"4","key":"b11","series-title":"Neurosurgery","first-page":"903","article-title":"Predictors of clinical and angiographic outcome after surgical or endovascular therapy of very large and giant intracranial aneurysms","volume":"68","author":"Darsaut TE","year":"2011","unstructured":"Darsaut TE, Darsaut NM, Chang SD, Predictors of clinical and angiographic outcome after surgical or endovascular therapy of very large and giant intracranial aneurysms. Neurosurgery. 2011;68(4):903\u2013916."},{"issue":"4","key":"b12","series-title":"Neurol India","first-page":"984","article-title":"Microsurgery of giant intracranial aneurysm: a single institution outcome study","volume":"69","author":"Misra B","year":"2021","unstructured":"Misra B, Warade A, Rohan R, Sarit SMicrosurgery of giant intracranial aneurysm: a single institution outcome study. Neurol India. 2021;69(4):984\u2013990."},{"issue":"6","key":"b13","series-title":"Neurosurgery","first-page":"1261","article-title":"Giant intracranial aneurysms: evolution of management in a contemporary surgical series","volume":"69","author":"Sughrue ME","year":"2011","unstructured":"Sughrue ME, Saloner D, Rayz VL, Lawton MTGiant intracranial aneurysms: evolution of management in a contemporary surgical series. Neurosurgery. 2011;69(6):1261\u20131271."},{"key":"b14","first-page":"293","article-title":"Giant intracranial aneurysms: surgical treatment and analysis of risk factors","volume":"102","author":"Xu L","year":"2017","unstructured":"Xu L, Deng X, Wang S, Giant intracranial aneurysms: surgical treatment and analysis of risk factors. World Neurosurg.2017;102:293\u2013300."},{"issue":"1","key":"b15","series-title":"Turk Neurosurg","first-page":"53","article-title":"Clipping of large and giant aneurysms of anterior circulation","volume":"21","author":"Kars HZ","year":"2011","unstructured":"Kars HZ, Gurelik MClipping of large and giant aneurysms of anterior circulation. Turk Neurosurg. 2011;21(1):53\u201358."},{"issue":"10","key":"b16","series-title":"Neuroradiology","first-page":"819","article-title":"Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases","volume":"49","author":"Li MH","year":"2007","unstructured":"Li MH, Li YD, Fang C, Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases. Neuroradiology. 2007;49(10):819\u2013828."},{"issue":"5-6","key":"b17","series-title":"World Neurosurg","first-page":"752","article-title":"Microsurgical management of giant intracranial aneurysms: a single surgeon experience from Louisiana State University, Shreveport","volume":"81","author":"Nanda A","year":"2014","unstructured":"Nanda A, Sonig A, Banerjee AD, Javalkar VKMicrosurgical management of giant intracranial aneurysms: a single surgeon experience from Louisiana State University, Shreveport. World Neurosurg. 2014;81(5-6):752\u2013764."},{"key":"b18","first-page":"e190","article-title":"Evaluation of microsurgery for managing giant or complex cerebral aneurysms: a retrospective study","volume":"115","author":"Ota N","year":"2018","unstructured":"Ota N, Matsukawa H, Noda K, Evaluation of microsurgery for managing giant or complex cerebral aneurysms: a retrospective study. 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