Aneurysmal Neck Clipping as the Primary Treatment Option for Both Ruptured and Unruptured Middle Cerebral Artery Aneurysms

Abstract

ObjectiveAlthough middle cerebral artery (MCA) aneurysms are less amenable to coil embolization, an increasing number of studies support favorable endovascular treatment for them. The purpose of this study is to compare the outcomes of two different treatments (surgery versus coiling) and evaluate the benefits of surgical clipping for MCA aneurysms.MethodsHere we retrospectively analyzed the outcomes of 178 ruptured and unruptured MCA aneurysms treated in patients between September 2008 and April 2012. Parameters assessing treatment outcomes include degree of aneurysm occlusion, presence of regrowth, clinical status, and complications.ResultsAmong 178 MCA aneurysms, 153 were treated surgically. After a mean follow-up of 12 months, the surgery group showed a clinically significant complete occlusion rate (98%) compared with the coiling group (56%) (p<0.001). Follow-up radiologic evaluation showed a higher regrowth rate (four of 16 cases) in the coiling group than in the surgery group (one of 49 cases) (p=0.003). There was no statistically significant difference in favorable clinical outcome rate between the two groups. The procedure-related permanent morbidity and mortality rates were 2% (three of 153 cases) in the surgery group and 0% (0 of 25 cases) in the coiling group.ConclusionCompared to endovascular treatment, surgical neck clipping for both ruptured and unruptured MCA aneurysms results in a significantly higher complete obliteration rate and less regrowth. Therefore, even in this endovascular era, we still recommend surgical clipping as the primary treatment option for MCA aneurysms rather than coil embolization.

Endovascular Treatment of Unruptured MCA Bifurcation Aneurysms Regardless of Aneurysm Morphology: Short- and Long-Term Follow-Up

“…7 In direct comparison with surgical clipping, the mortality rate after the endovascular technique was at least equal to recent published data (1.9%-2.0%). 8,9 We found a good clinical outcome (mRS Ϲ 2) in 91.3% directly after discharge and in 89.8% after long-term follow-up. In their comparative analysis, McDonald et al 7 found a similar in-hospital mortality risk, but in long-term follow-up, the outcome in surgical treatment was significantly worse than after endovascular technique.…”

Preventing Rupture: Clipping of Unruptured Intracranial Aneurysms

“…Despite clipping once being the management centerpiece, the swift refinement of endovascular procedures and innovation of flow diversion devices have steadily replaced surgery as the first line of therapy for UIAs. However, certain countries still favor clipping due to its longevity, effectiveness, and the lower risk of recanalization than endovascular techniques, as well as lower procedure-related costs [75][76][77]. Consequently, whereas older patients who are unsuitable for surgery may benefit the most from endovascular procedures, clipping is considered preferable for younger patients with lower-grade aneurysms and that may be able to tolerate this intervention [76,78].…”

“…Likewise, MCA aneurysms, which are generally considered more easily approached by surgery, were grossly underrepresented in this study. Several authors obtained much higher rates of complete obliteration via clipping than through endovascular procedures for aneurysms in this location [77,81,82]. This is more likely a consequence of the particular configurations of MCA aneurysms, rendering it more difficult to completely occlude the neck via endovascular procedures (wide-necked, possessing a small dome-to-neck ratio, the neck encompassing one of the arterial branches, etc.)…”

“…This is more likely a consequence of the particular configurations of MCA aneurysms, rendering it more difficult to completely occlude the neck via endovascular procedures (wide-necked, possessing a small dome-to-neck ratio, the neck encompassing one of the arterial branches, etc.) [77]. Moreover, these aneurysms are generally adjacent to or surrounded by small perforators that may prohibit the use of stents.…”

“…Another controversial subject is the management of aneurysm remnant or repermeabilization after clipping or coiling. It has been repeatedly demonstrated that microsurgery leads to fewer such instances [75][76][77][78][79][80][81][82]. Although the issue of hemorrhage after initial treatment and its consequences have been extensively covered for ruptured aneurysms, there is currently no such data for UIAs [39].…”