ABSTRACT
Despite the improvements in increasing popularity of endovascular therapy for intracranial aneurysms, there remain a large number of these lesions that currently are not amenable to endovascular therapy. As endovascular therapy becomes more popular, those aneurysms requiring surgical intervention will become increasingly complex. To manage these challenging lesions, neurosurgeons must use all available innovations and advances, including diagnostic, technical and perioperative adjuncts. In this review article, we discuss limitations of endovascular therapy, the populations of aneurysms that continue to require surgical treatment, the factors that make an aneurysm complex and the multiple adjuncts utilized to successfully treat these challenging lesions.