Advances in multimodality treatment of cerebral aneurysms

Background: The treatment of intracranial aneurysms has undergone a paradigm shift such that endovascular therapy has emerged as a viable treatment regimen. Thus, microsurgery techniques have become less invasive, more appealing to patients, lower risk, and efficacious for complex aneurysms, particularly those unfavorable for or failing endovascular therapy. Methods: We reviewed literature and emphasized major modern techniques used in complex aneurysm treatment. Also we present several cases of minimal invasive supraorbital „keyhole” craniotomy, used in treatment of anterior circulation aneurysms and a case report of a giant cavernous carotid aneurysm resolved with an extra-intracranial high-flow bypass and trapping of parent vessel. Results: Multimodality treatment of cerebral aneurysm provided by literature can be divided in two major groups: microsurgery and endovascular techniques. Microsurgery include: direct clip occlusion via a large or minimal invasive craniotomy, clip occlusion after coil extraction and bypass techniques; while endovascular techniques embrace: coiling, stent/balloon-assisted coiling and pipeline endovascular device flow diverter. Conclusion: Contemporary management strategies should involve all aspects of neurovascular care, including neuroendovascular physicians, neurocritical care, and neuroanesthesia. All of these specialties should be synergistic and complementary in their approach with the common goal of managing the obliteration of the aneurysm with minimal risk, both short-term and long-term, to the patient