Techniques and outcomes for microsurgical treatment of large and giant cerebral aneurysms in the endovascular era.

[OBJECTIVE] Large and giant intracranial aneurysms (LGIA) pose significant surgical challenges due to their complex anatomy, high risk of rupture, and severe morbidity and mortality rates. The aim of this study was to evaluate microsurgical treatment techniques and outcomes for LGIA as an alternative to endovascular treatment methods.

[METHODS] Intracranial aneurysms treated with microsurgery by a single surgeon from January 2006 to February 2025 were retrospectively analyzed. Demographic data, clinical presentations, aneurysm characteristics, surgical techniques, complications, and outcomes were evaluated. Outcomes were evaluated based on patients' neurological conditions, with functional recovery levels and predictive factors investigated using multivariate logistic regression analysis.

[RESULTS] Of 127 patients (80 female, mean age 57.9 years) with LGIA included in the analysis, 99 had large (10-24 mm) and 28 had giant (≥ 25 mm) aneurysms. The mean aneurysm size was 18.4 mm. Aneurysms were most commonly located in the middle cerebral artery (41.7%) and were most frequently treated with primary clipping (72.4%), clip reconstruction (12.6%), and bypass (10.2%). The occlusion rate was 94.5% on postoperative imaging. Surgical complications were observed in 13.4% of patients, while nonsurgical complications were observed in 18.9%. The neurological status of 91.3% of patients improved or remained unchanged. Vasospasm was an independent predictor of poor prognosis (p = 0.019).

[CONCLUSIONS] Microsurgical treatment of LGIA was safe and effective, with high occlusion rates and acceptable morbidity and mortality. Appropriate patient selection, detailed surgical planning, and experienced surgical technique play a critical role in achieving successful outcomes. Despite the increasing use of endovascular techniques, microsurgery remains a fundamental strategy in the management of LGIA.