Journal of the Louisiana State Medical Society
Surgical Management of Middle Cerebral Artery Aneurysms
Anil Nanda, MD; Sudheer Ambekar, MD; Mayur Sharma, MD
Objectives : Treatment of middle cerebral artery (MCA) aneurysms remains controversial because of their morphological characteristics. The aim of our study was to analyze the morbidity, mortality, and outcome of patients who underwent clipping of MCA aneurysms and compare with that of endovascular therapy. Patients and Methods : Patient and aneurysm characteristics and treatment outcomes of patients treated by the senior author from 1992 through 2012 were analyzed. Various factors associated with good outcome were analyzed. Results : One hundred twenty-five patients with 132 aneurysms were included in the study. Seven patients had bilateral MCA bifurcation aneurysms, and 11 were giant aneurysms. Ninety-two point four percent aneurysms were located at MCA bifurcation, others being at pre- or post-bifurcation segments of M1. Intra- operative rupture was encountered in 4.8%. The overall perioperative morbidity and mortality was 8% and 0.8%, respectively. At a mean follow-up of 19.3 months, 83.8% patients had good outcome (mRS 0 and 1). The angiographic obliteration rate at one-year follow-up was 98%. Good preoperative Hunt and Hess grade and unruptured aneurysmwere significantly associated with good outcome, whereas presence of hematoma was associated with poor outcome following surgery (P<0.05). Conclusions : The results of clipping of MCA aneurysms are superior to that of published endovascular therapy. Surgical clipping remains the standard of care for MCA aneurysms with good clinical and angio- graphic outcome.
INTRODUCTION Since the International Subarachnoid Aneurysm Trial (ISAT), 1 there has been a dramatic shift in the treatment paradigm of intracranial aneurysms towards coiling. With the rapid advances in coil technology, increasing proportion of aneurysms are being coiled each year compared to the previous year. Although the middle cerebral artery (MCA) can be easily catheterized, MCA aneurysms pose a unique challenge to endovascular therapy due to their unfavorable morphology. Factors that makeMCA aneurysms unsuitable for endovascular therapy include location of the aneurysm at MCA trifurcation, incorporation of one of the branches by the aneurysm, lowdome-to-neck ratio, and parent vessel incorporation. There has been discussion as to which modality of treatment is better for treatment of MCA aneurysms. 2-4 Some studies have found an inferior outcome following endovascular treatment, whereas in others, the outcome is the same as surgical clipping. We report the experience of the senior author (AN) with surgical clipping of MCA aneurysms and compare the outcome with the outcomes following endovascular treatment as published in literature.
PATIENTS AND METHODS The study was approved by the Institutional Review Board. This was a retrospective study of all patients with MCA aneurysms who underwent surgical clipping between 1992 and August 2012. Patients with traumatic and mycotic aneurysms were excluded from the study. The demographic profile, clinical presentation, and aneurysm rupture status of all the patients was obtained from a prospectively collected database. Patients were classified clinically according to the Hunt and Hess score at admission. 5 Aneurysm size, loca- tion, and other angiographic characteristics were obtained from the digital subtraction angiograms and computed tomographic angiograms (CTA). Aneurysms were sorted into three groups depending on the size: (1) 0 to 10 mm, (2) 11 to 24 mm, and (3) greater than or equal to 25 mm. All patients underwent surgery via the pterional approach. Patients who were diagnosed to have bilateral MCA aneurysms underwent surgery for the ruptured aneurysm first followed by surgery for the other MCA aneurysm in another sitting. Intraoperative aneurysm occlusion was assessed by visual examination in all cases, intraoperative angiography in a few cases, and with near infrared indo- cyanine green videoangiography (ICGA) during the latter
160 J La State Med Soc VOL 166 July/August 2014
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