Treatment of giant aneurysms of the cavernous portion of the internal carotid artery

Giant aneurysms of the cavernous portion of the carotid artery are intriguing and challenging lesions. Decisions about treatment should be solidly based on cerebrovascular anatomical and physiologic principles. A broad spectrum of direct and indirect methods for treating these lesions is available. Advances in surgical technique, preoperative and intraoperative imaging, and cerebrovascular physiologic assessment have enhanced direct approaches. The importance of knowing who, what, where, when, and how to approach these lesions is discussed. Careful consideration and application of these factors are advocated in the treatment of these challenging vascular lesions.