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Contralateral Clipping of Middle Cerebral Artery Aneurysms: Rationale, Indications, and Surgical Technique

Rodríguez-Hernández, Ana MD*; Gabarrós, Andreu MD; Lawton, Michael T. MD*

doi: 10.1227/NEU.0b013e31824d8f66
Technique Assessment

BACKGROUND: Contralateral clipping of middle cerebral artery (MCA) aneurysms seems dangerous and ill advised but could become an important technique because of the prevalence of MCA aneurysms, the limitations of endovascular therapy, and increasing interest in less invasive techniques.

OBJECTIVE: To define patient selection, surgical technique, and results with contralateral MCA aneurysm clipping.

METHODS: Forty-two patients with bilateral MCA aneurysms were treated either in 1 stage with a single craniotomy and contralateral aneurysm clipping (group 1, 11 patients) or in 2 stages with bilateral craniotomy (group 2, 31 patients). Surgical technique consisted of ipsilateral sylvian fissure split, subfrontal dissection, contralateral sylvian fissure split, mobilization of medial orbital gyrus, and contralateral aneurysm clipping.

RESULTS: Group 1 patients were older than group 2 patients (60.3 vs 55.4 years, respectively). Clinical presentation with subarachnoid hemorrhage was less common in group 1. Nine group 1 patients (82%) had left-sided craniotomies, and the ipsilateral aneurysm was larger than the contralateral aneurysm. All aneurysms were clipped without intraoperative complications (136 aneurysms). Mean neurosurgical charges were decreased by contralateral MCA aneurysm clipping: $39 297 in group 1 vs $57 977 in group 2.

CONCLUSION: Contralateral MCA aneurysm clipping can be viewed as an extreme microsurgical technique or as a less invasive technique that spares patients a second craniotomy in the management of bilateral aneurysms. This technique is acceptable in selected patients with contralateral aneurysms that are unruptured, have simple necks, project inferiorly or anteriorly, are associated with short M1 segments, and reside in older patients with sylvian fissures widened by brain atrophy.

ABBREVIATIONS: ACA, anterior cerebral artery

ICA, internal carotid artery

MCA, middle cerebral artery

mRS, modified Rankin Scale

*Department of Neurological Surgery, University of California, San Francisco, California

Department of Neurological Surgery, Hospital de Bellvitge, Barcelona, Spain

Correspondence: Michael T. Lawton, MD, Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave, M780, San Francisco, CA 94143-0112. E-mail:

Received September 26, 2011

Accepted January 4, 2012

Copyright © by the Congress of Neurological Surgeons