In the June issue of Journal of Neurosurgery Siddiqui et al present their retrospective analysis of 7 patients presenting with symptomatic large or giant fusiform vertebrobasilar aneurysms treated with flowdiverters (1). Six patients were treated with Pipeline devices, and one patient with Silk device. The treatments were done between October 2009 and August 2011. At follow up 4 patients had died, 2 due to aneurysm rupture. One patient had severe disability and 2 patients have mRS scores of 0-1. Reflecting the nature of this disease the authors report that during the study period three patients died while waiting for the treatment.

The treatment of this extremely complex disease remains unsolved, the initial good angiographic results achieved with flowdiverters, especially in the internal carotid artery, are promising, but in these fusiform large aneurysms of the posterior circulation the concept of endovascular flow diversion must be questioned and rethinked. The poor natural history does not seem to improve with this method of treatment. Traditional flow diversion done by vessel occlusion combined with by-pass surgery remains an option for selected patients.