Endovascular and Open Surgical Procedures for Complex Intracranial Aneurysms: A Systematic Review

Introduction: Intracranial aneurysm rupture leads to severe neurological complications, with mortality rates up to 50%. Microsurgical clipping was the first established treatment, followed by the advent of endovascular techniques. However, it is noticeable that in some cases, especially complex aneurysms, a multimodal treatment seems to be the new future. This paper aims to evaluate the results, indications, and complications of the combined approaches.

Methods: We performed a systematic search of PubMed, Web of Science, and Scopus using the following keywords and their synonyms: “Aneurysm”, “Endovascular” and “Microsurgery”. Only studies on IAs in humans were included. The selection criteria involved articles that performed both procedures on the same patient.

Results: Our review included 17 studies, of which 23.52% were retrospective, 35.29% were case series, and 41.17% were case reports, with 187 patients. 64,2% were female, 35,8% were male, and the mean age of 47.86 years. The mean aneurysm size according to the studies reporting was 15.18mm. In terms of the occurrence of subarachnoid hemorrhage, we identified a 31.5% incidence. Regarding aneurysm rupture status, 54.2% were unruptured, while 45.8% had ruptured. As for aneurysm location, 45.3% were found in the middle cerebral artery, 32.8% in the internal carotid artery, and 21.9% in the basilar artery. Furthermore, in the context of the combined treatment approaches, the initial intervention was endovascular in 45.5% of cases, compared to 54.5% that underwent a surgical approach. For secondary treatment, 1/3 of cases were treated endovascularly, while 2/3 we submitted to surgery. Among endovascular procedures, 98.1% used coils, and 1.9% used stents. Surgical methods consisted of bypass procedures in 72.8% of cases and clipping in 27.2%. Outcomes indicated a mortality rate of 3.74%. A modified Rankin Scale score of 0–2 was achieved in 31% of cases. Complete aneurysm occlusion was observed in 47.6% of patients.

Conclusion : This systematic review concludes that the combined approach holds significant potential in the field of vascular neurosurgery. However, further studies are necessary to ensure greater efficacy in the treatment of intracranial aneurysms.