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Current Management of Middle Cerebral Artery Aneurysms: Surgical Results With a Clip First Policy

Rodríguez-Hernández, Ana MD; Sughrue, Michael E. MD; Akhavan, Sina BS; Habdank-Kolaczkowski, Julian BS; Lawton, Michael T. MD

doi: 10.1227/NEU.0b013e3182804aa2
Research-Human-Clinical Studies

BACKGROUND: One response to randomized trials like the International Subarachnoid Aneurysm Trial has been to adopt a “coil first” policy, whereby all aneurysms be considered for coiling, reserving surgery for unfavorable aneurysms or failed attempts. Surgical results with middle cerebral artery (MCA) aneurysms have been excellent, raising debate about the respective roles of surgical and endovascular therapy.

OBJECTIVE: To review our experience with MCA aneurysms managed with microsurgery as the treatment of first choice.

METHODS: Five hundred forty-three patients with 631 MCA aneurysms were managed with a “clip first” policy, with 115 patients (21.2%) referred from the Neurointerventional Radiology service and none referred from the Neurosurgical service for endovascular management.

RESULTS: Two hundred eighty-two patients (51.9%) had ruptured aneurysms and 261 (48.1%) had unruptured aneurysms. MCA aneurysms were treated with clipping (88.6%), thrombectomy/clip reconstruction (6.2%), and bypass/aneurysm occlusion (3.3%). Complete aneurysm obliteration was achieved with 620 MCA aneurysms (98.3%); 89.7% of patients were improved or unchanged after therapy, with a mortality rate of 5.3% and a permanent morbidity rate of 4.6%. Good outcomes were observed in 92.0% of patients with unruptured and 70.2% with ruptured aneurysms. Worse outcomes were associated with rupture (P = .04), poor grade (P = .001), giant size (P = .03), and hemicraniectomy (P < .001).

CONCLUSION: At present, surgery should remain the treatment of choice for MCA aneurysms. Surgical morbidity was low, and poor outcomes were due to an inclusive policy that aggressively managed poor-grade patients and complex aneurysms. This experience sets a benchmark that endovascular results should match before considering endovascular therapy an alternative for MCA aneurysms.

ABBREVIATIONS: ICG, indocyanine green

ISAT, International Subarachnoid Aneurysm Trial

MCA, middle cerebral artery

mRS, modified Rankin score

SAH, with subarachnoid hemorrhage

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

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

Received April 01, 2012

Accepted November 26, 2012

Copyright © by the Congress of Neurological Surgeons