{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T08:28:42Z","timestamp":1771921722453,"version":"3.50.1"},"reference-count":22,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,1,14]],"date-time":"2026-01-14T00:00:00Z","timestamp":1768348800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Endovascular coiling for intracerebral aneurysms has been evolving. Yet, large and giant aneurysms (LAGA) remain a significant challenge in any treatment modality and carry high rates of morbidity and mortality.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>The SMART registry, a prospective, multicenter site-adjudicated trial, was used to identify patients with LAGA (Sac 10\u201325\u202fmm for large and &amp;gt;25\u202fmm for giant) treated with the Penumbra SMART COIL (SMART) system and compare their outcomes to patients with smaller aneurysms (SA; Sac\u202f\u2264\u202f10\u202fmm). Aneurysm occlusion per Raymond-Roy (RROC) scale, recanalization, retreatment, mortality, and serious device-related adverse events (SAEs) were analyzed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 133\/905 (14.7%) enrolled patients had LAGA with a mean (SD) aneurysm size of 13.7 (3.59) mm for LAGA and 5.8 (1.95) mm for SA. LAGA were more likely to be non-saccular (24.1% vs. 12.3%,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.0007) and wide-necked (69.9% vs. 59.7%,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.0268) compared to SA. Primary coiling was the main treatment modality for LAGA and SA (43.6% vs. 43.3%;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f1.0). However, LAGA were more likely to be treated with flow diversion in addition to coiling (6.0% vs. 1.0%,\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001). At 1-year follow-up: (i) RROC I-II was 82.7% in LAGA and 91.2% in SA;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.0166, (ii) recanalization rates were 13.8% vs. 12.7%;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.7417, and retreatment rates were 11.5% vs. 6.4%;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.0648, for LAGA and SA, respectively, and (iii) all-cause mortality was 9.8% in LAGA vs. 4.7% SA;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.0222. The device-related SAEs rates were low and comparable between the two study groups (4.5% vs. 4.1%;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.8153).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The SMART registry demonstrated that endovascular coiling can be feasible and safe in patients with LAGA, however randomized controlled studies are needed for comparative effectiveness.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Clinical trial registration<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link>https:\/\/clinicaltrials.gov\/study\/NCT02729740<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fneur.2025.1670622","type":"journal-article","created":{"date-parts":[[2026,1,14]],"date-time":"2026-01-14T13:52:49Z","timestamp":1768398769000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Large and giant intracranial aneurysms: outcomes from the multicenter prospective SMART coils registry"],"prefix":"10.3389","volume":"16","author":[{"given":"Yazan","family":"Ashouri","sequence":"first","affiliation":[{"name":"St. Vincent Mercy Health Medical Center","place":["Toledo, OH, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexandra R.","family":"Paul","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Albany Medical Center","place":["Albany, NY, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohammad","family":"AlMajali","sequence":"additional","affiliation":[{"name":"St. Vincent Mercy Health Medical Center","place":["Toledo, OH, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Amit","family":"Chaudhari","sequence":"additional","affiliation":[{"name":"St. Vincent Mercy Health Medical Center","place":["Toledo, OH, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eugene","family":"Lin","sequence":"additional","affiliation":[{"name":"St. Vincent Mercy Health Medical Center","place":["Toledo, OH, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Min S.","family":"Park","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Virginia Health","place":["Charlottesville, VA, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard J.","family":"Bellon","sequence":"additional","affiliation":[{"name":"Department of Neurointerventional Surgery, Radiology Imaging Associates (RIA) Neurovascular","place":["Englewood, CO, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bradley N.","family":"Bohnstedt","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Indiana University Health","place":["Indianapolis, IN, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Albert J.","family":"Yoo","sequence":"additional","affiliation":[{"name":"Department of Interventional Neuroradiology, Texas Stroke Institute","place":["Dallas, TX, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Clemens M.","family":"Schirmer","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Geisinger Medical Center","place":["Danville, PA, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Reade A.","family":"DeLeacy","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Mount Sinai Hospital","place":["New York, NY, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David J.","family":"Fiorella","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Stony Brook University Medical Center","place":["Stony Brook, NY, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Keith","family":"Woodward","sequence":"additional","affiliation":[{"name":"Fort Sanders Regional Medical Center","place":["Knoxville, TN, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Harris E.","family":"Hawk","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Erlanger Health System Chattanooga","place":["Chattanooga, TN, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ashish","family":"Nanda","sequence":"additional","affiliation":[{"name":"Providence St. Jude Medical Center","place":["Fullerton, CA, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter J.","family":"Sunenshine","sequence":"additional","affiliation":[{"name":"Banner \u2013 University Medical Center Phoenix","place":["Phoenix, AZ, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mouhammed R.","family":"Kabbani","sequence":"additional","affiliation":[{"name":"Gundersen Health System","place":["La Crosse, WI, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kenneth V.","family":"Snyder","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Buffalo","place":["Buffalo, NY, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thinesh","family":"Sivapatham","sequence":"additional","affiliation":[{"name":"Christiana Care Health System","place":["Newark, DE, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Travis M.","family":"Dumont","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Arizona","place":["Tucson, AZ, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alan R.","family":"Reeves","sequence":"additional","affiliation":[{"name":"Department of Radiology, University of Kansas","place":["Kansas City, KS, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert M.","family":"Starke","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Miami Hospital","place":["Miami, FL, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alejandro M.","family":"Spiotta","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of South Carolina","place":["Charleston, SC, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Osama O.","family":"Zaidat","sequence":"additional","affiliation":[{"name":"St. Vincent Mercy Health Medical Center","place":["Toledo, OH, United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,1,14]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"626","DOI":"10.1016\/S1474-4422(11)70109-0","article-title":"Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis","volume":"10","author":"Vlak","year":"2011","journal-title":"Lancet Neurol"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"1725","DOI":"10.1056\/NEJM199812103392401","article-title":"Unruptured intracranial aneurysms\u2014risk of rupture and risks of surgical intervention","volume":"339","year":"1998","journal-title":"N Engl J Med"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"393","DOI":"10.1016\/S1474-4422(14)70015-8","article-title":"Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening","volume":"13","author":"Brown","year":"2014","journal-title":"Lancet Neurol"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"365","DOI":"10.1161\/STROKEAHA.115.010698","article-title":"Risk analysis of unruptured intracranial aneurysms: prospective 10-year cohort study","volume":"47","author":"Murayama","year":"2016","journal-title":"Stroke"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"178","DOI":"10.1016\/S0720-048X(03)00090-1","article-title":"Giant intracranial aneurysms: development, clinical presentation and treatment","volume":"46","author":"Choi","year":"2003","journal-title":"Eur J Radiol"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"1267","DOI":"10.1016\/S0140-6736(02)11314-6","article-title":"International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial","volume":"360","author":"Molyneux","year":"2002","journal-title":"Lancet"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"146","DOI":"10.3171\/2013.3.JNS12683","article-title":"The Barrow ruptured aneurysm trial: 3-year results: clinical article","volume":"119","author":"Spetzler","year":"2013","journal-title":"J Neurosurg"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"546","DOI":"10.3174\/ajnr.A3696","article-title":"Coiling of large and giant aneurysms: complications and long-term results of 334 cases","volume":"35","author":"Chalouhi","year":"2014","journal-title":"AJNR Am J Neuroradiol"},{"key":"ref9","first-page":"257","article-title":"Coiling of very large or giant cerebral aneurysms: long-term clinical and serial angiographic results","volume":"24","author":"Sluzewski","year":"2003","journal-title":"AJNR Am J Neuroradiol"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"793","DOI":"10.1097\/00006123-199910000-00013","article-title":"Clinical and angiographic results of endosaccular coiling treatment of giant and very large intracranial aneurysms: a 7-year, single-center experience","volume":"45","author":"Gruber","year":"1999","journal-title":"Neurosurgery"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"1398","DOI":"10.1161\/01.STR.0000073841.88563.E9","article-title":"Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils","volume":"34","author":"Raymond","year":"2003","journal-title":"Stroke"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"637551","DOI":"10.3389\/fneur.2021.637551","article-title":"The SMART registry: long-term results on the utility of the penumbra SMART COIL system for treatment of intracranial aneurysms and other malformations","volume":"12","author":"Spiotta","year":"2021","journal-title":"Front Neurol"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"1998","DOI":"10.1161\/hs0901.095600","article-title":"Endovascular treatment of unruptured aneurysms","volume":"32","author":"Roy","year":"2001","journal-title":"Stroke"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"14","DOI":"10.3171\/jns.1968.28.1.0014","article-title":"Surgical risk as related to time of intervention in the repair of intracranial aneurysms","volume":"28","author":"Hunt","year":"1968","journal-title":"J Neurosurg"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"200","DOI":"10.1177\/1591019920956890","article-title":"Long-term follow-up results of the SMART coil in the endovascular treatment of intracranial aneurysms","volume":"27","author":"McAvoy","year":"2021","journal-title":"Interv Neuroradiol"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"654","DOI":"10.1177\/1591019916663479","article-title":"Early experience with the penumbra SMART coil in the endovascular treatment of intracranial aneurysms: safety and efficacy","volume":"22","author":"Stapleton","year":"2016","journal-title":"Interv Neuroradiol"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1186\/s12883-020-1623-9","article-title":"SMART coils for intracranial aneurysm repair\u2014a single center experience","volume":"20","author":"Daniel","year":"2020","journal-title":"BMC Neurol"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1016\/j.wneu.2016.06.009","article-title":"Initial technical experience with the SMART coil for the embolization of intracranial aneurysms","volume":"97","author":"Alejandro","year":"2017","journal-title":"World Neurosurg"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1177\/0284185113520312","article-title":"Endovascular embolization is applicable for large and giant intracranial aneurysms: experience in one center with long-term angiographic follow-up","volume":"56","author":"Wang","year":"2015","journal-title":"Acta Radiol"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"15910199231196329","DOI":"10.1177\/15910199231196329","article-title":"Device use trends in neuroendovascular procedures in the United States from 2015 to 2020","author":"Adapa","year":"2023","journal-title":"Interv Neuroradiol"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1016\/j.jocn.2011.03.038","article-title":"A single-centre experience and follow-up of patients with endovascular coiling of large and giant intracranial aneurysms with parent artery preservation","volume":"19","author":"Gao","year":"2012","journal-title":"J Clin Neurosci"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"e507","DOI":"10.1016\/j.wneu.2020.08.213","article-title":"Long-term outcome of endovascular therapy for large or giant thrombosed intracranial aneurysms","volume":"144","author":"Enomoto","year":"2020","journal-title":"World Neurosurg"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2025.1670622\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T06:54:24Z","timestamp":1771916064000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2025.1670622\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,14]]},"references-count":22,"alternative-id":["10.3389\/fneur.2025.1670622"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2025.1670622","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,14]]},"article-number":"1670622"}}