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Surgical and Endovascular Management of Cerebral Aneurysms

Intracranial aneurysms represent one of the most challenging pathologies a neurosurgeon can encounter. Not only does the treatment of an intracranial aneurysm require significant technical ability, but the decision-making process of choosing which lesions to treat and how to treat them remains often just as difficult. Subarachnoid hemorrhage from a ruptured aneurysm carries a grave prognosis, despite best medical therapies. If left untreated, a ruptured aneurysm has a significantly high risk for rerupture. Little controversy exists in the decision to treat an acutely ruptured aneurysm. However, which treatment modality (surgical clipping vs. endovascular obliteration) remains a topic of debate. Furthermore, physicians know that intracranial aneurysms carry a high risk of patient morbidity and mortality if they hemorrhage and if ruptured require immediate treatment. However, exactly which aneurysms are likely to progress to rupture, how best to treat those high-risk lesions, and how best to secure a ruptured aneurysm remains hotly contested among vascular and endovascular neurosurgeons as well as interventional neuroradiologists and neurologists. In this chapter, the natural history, epidemiology, pathophysiology, and various forms of treatment for intracranial aneurysms will be discussed.