Endovascular Versus Surgical Management of Intracranial Pseudoaneurysms: A Comparative Review

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Intracranial pseudoaneurysms (IPAs) are uncommon cerebral lesions that are quite difficult to treat because they have high rates of rupture and deaths. This narrative review provides a comparison between the surgical and endovascular modalities of treatment of IPAs, paying attention to efficacy, durability, application, and safety. There was traditionally the gold standard of a definitive cure and that is open surgery; even clipping, trapping with bypass, and that old standard of wrapping. The methods, however, are physiologically challenging and they have high morbidity. Less invasive alternatives endovascularly include coiling, parent artery occlusion, and flow diversion which has the benefit of leaving the parent artery intact in greater than 90% of cases. Surgical trapping and bypass are the most definitive treatment, have high occlusion rates and low recurrence, and necessitate parent sacrifice. Endovascular reconstructive techniques are instant remedial and protect the parent vessel, but the long-term resilience is variable. Flow diversion is promising with rates of complete occlusion but increases risks of delayed thrombosis, and rupture. Higher morbidity and mortality are linked to surgical management because of craniotomy and repair of vessels, and endovascular complications are mostly thromboembolic and ischemic stroke. The variables taken into consideration to select a model of treatment include: the patient (age, comorbidities, neurological status), the aneurysm (location, size, morphology) and institutional (expertise, resources). IPAs are rare; most of the available evidence is retrospective in nature and prone to selection bias, as well as heterogeneity in recording. It should be multidisciplinary and tailored to the patient and would use an endovascular intervention with surgery only in more complex cases or those refractories to endovascular management. It is important to develop quality improvement programs and coordinate partnerships between endovascular experts and neurosurgeons in order to maximize patient outcomes.