Treatment Modalities of Complex Anterior Circulation Intracranial Aneurysms

Background Complex intracranial aneurysms (CIAs) are the most technically demanding neurosurgical pathologies. Although extensive work and effort has been directed to the treatment of these challenging vascular lesions, no formal definition exists on what complex aneurysms are, and it is rather subjective to individual interpretation that an aneurysm receives such label. Aim of the Study The overall aim of the study is to assess the clinical outcomes of the different modalities in management of complex intracranial anterior circulation aneurysms and to try to set up a clear and concrete treatment algorithm for the management dilemma. Patients and Methods This study is a prospective observational study that included 40 patients. All patients were evaluated by an interdisciplinary conference consisting of neuroendovascular surgeons and vascular neurosurgeons for assessment of the therapeutic options and the suitability of endovascular and/or surgical treatment. Initially, study setting was supposed to be in Ain Shams University teaching hospitals, Egypt, King’s College Hospital, United Kingdom and Barrow’s Neurological institute, USA. Unfortunately, due to COVID-19 Pandemic, Cases from King’s College Hospital in London were only included. Results Twenty cases were managed surgically, while 18 were treated by different endovascular techniques. Both surgical and endovascular modalities were used as a hybrid approach to treat 2 cases. Recurrence of treated aneurysms was seen only in the endovascular modality. Four cases out of the 18 cases treated by endovascular techniques showed either residual or recurrence of the previously treated aneurysms. Four documented intervention related mortalities occurred during the first 6 months. Two cases out of the 4 were treated by endovascular techniques (balloon assisted coiling & parent vessel occlusion), one case was surgically treated by clip/wrap technique and the last mortality was seen in a case treated by the hybrid approach (Clipping+ flow diverter). Conclusion Complex intracranial aneurysms managed surgically showed less recurrence rate than those treated by different endovascular techniques. CIAs treated by endovascular modalities showed much lower length of hospital stay and better modified Rankin scale after 6 months. Complications rate and mortality rate were nearly similar in both groups and were usually related to the initial poor presentation with hight WFNS grade upon the initial ictus.