Purpose:
Wide-necked (neck diameter > 4 mm or dome-to-neck ratio < 2) large and giant aneurysms (> 15 mm) possess an inherent increased risk of rupture compared to smaller and narrow-neck intracranial aneurysms. Endovascular treatment may be challenging with higher complication risks of infarct and re-canalization of the aneurysm sac in this particular population. Herein, we present a background of the current endovascular devices available for the treatment of wide-neck large and giant intracranial aneurysms. We review the landmark trials and present several case studies from our institution showcasing these devices.
Approach/Methods:
A literature review will be performed, with special focus on the background, indications, safety/efficacy, and complication risks of established and novel devices used in the treatment of wide-necked and large aneurysms. Several cases from our institution with a busy neuro- interventional service showcasing these devices will be selected for presentation.
Findings/Discussion:
Flow diverters and balloon-/stent-assisted coiling are the best studied and most commonly used approaches for treatment. The 5-year follow-up of the Pipeline for Uncoilable or Failed Aneurysms (PUFS) clinical trial of 107 subjects demonstrated high safety and efficacy of the Pipeline Embolization Device (PED) with low complication risks. A recent 2019 meta-analysis of 29 studies demonstrated comparable safety and efficacy with flow diverters and coiling techniques. Several techniques such as intra-aneurysmal devices/implants (ie. WEB) and bifurcation support systems are increasingly being utilized and several studies have shown comparable safety and efficacy.
Summary/Conclusion:
Wide-necked large and giant aneurysms possess an inherent increased risk of rupture and are more challenging to treat when compared to smaller and narrow-neck intracranial aneurysms. Factors such as anatomy, size, neck diameter, and location should be considered when choosing the optimal method of approach. It is important for the neuro-interventionalist to evaluate all treatment options when attempting to manage this entity.

A comparative review of current endovascular treatments of wide-necked large and giant aneurysms

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