ArticleFrontiers in surgery2026
Contemporary indications and outcomes of open surgical cerebral aneurysm management in the endovascular era.
Article in Frontiers in surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background and objective: In the current endovascular era, only a minority of intracranial aneurysms (IA) are treated surgically. This study aims to delineate the contemporary indications and outcomes of open microsurgical treatment. Methods: Retrospective single-center analysis of patients treated for IA between 2019 and 2023, including ruptured and unruptured cases. Our center follows an "interventional-first" strategy, reserving surgery for aneurysms deemed unsuitable for endovascular therapy. For each surgical case, the reason for endovascular unsuitability and the corresponding outcome were assessed. Results: A total of 432 aneurysms were analyzed, of which 39.1% were treated with open surgery and 60.9% with endovascular therapies. In the surgical cohort (140 patients, 169 treated aneurysms), 41.4% of cases presented with subarachnoid hemorrhage. The main morphological reasons for selecting open surgery were wide-necked aneurysms (27%), branch incorporation at the neck (19%), and very small aneurysm size (<3 mm) (8.6%). A substantial proportion of bystander aneurysms (17.2%) were treated surgically because the index aneurysm required open surgery, allowing simultaneous treatment. Prior endovascular treatment had been performed in 15.7% of surgical cases. Adjunctive techniques to clipping, including anterior or posterior clinoidectomy, were necessary in 9.3% of cases. Cerebral bypass and trapping were required in 5.7% of cases, typically for large, calcified aneurysms with stenotic parent arteries. Complete aneurysm occlusion was achieved in 93.3% of cases. Major and minor complication rates were 3.6% and 7.9%, respectively. Conclusion: This study outlines contemporary indications for open surgery in the endovascular era and supports the complementary role of microsurgery within an integrated treatment strategy. Microsurgical treatment achieved high rates of complete aneurysm occlusion with acceptable morbidity, even in complex and previously endovascularly treated lesions. Careful patient selection and the use of adjunctive skull base and bypass techniques remain essential.
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