Outcomes of Microsurgical Clipping in Middle Cerebral Artery Aneurysms

Abstract Middle cerebral artery aneurysms, a common source of subarachnoid hemorrhage, occur predominantly at the main bifurcation of the middle cerebral artery. Microsurgical clipping is the most effective treatment of these aneurysms because of their peripheral location, wide necks, and straightforward surgical anatomy. Despite the moderate technical requirements of this type of surgery, patients with ruptured aneurysms often have poor outcomes because of the high incidence of intracerebral hematomas. Although several different surgical approaches can be used, we favor a lateral-to-medial transsylvian approach for most aneurysms. This description of our surgical technique stresses minimizing retraction to avoid injury to the brain and preparing broad-based middle cerebral artery aneurysms for clipping. Management of outcomes when using these techniques also is presented.

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Surgical clipping of a large left middle cerebral artery aneurysm

Neurosurgical FOCUS ◽

10.3171/2015.v1.focus14555 ◽

2015 ◽

Vol 38 (videosuppl1) ◽

pp. Video13

Author(s):

M. Yashar S. Kalani ◽

Peter Nakaji ◽

Joseph M. Zabramski ◽

Robert F. Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Artery Aneurysm ◽

Left Middle Cerebral Artery ◽

Middle Cerebral Artery Aneurysm ◽

Surgical Clipping ◽

Microsurgical Clipping ◽

Middle Cerebral Artery Aneurysms ◽

Cerebral Artery Aneurysm ◽

Left Middle

Middle cerebral artery aneurysms, especially those with complex morphology, are considered excellent aneurysms for surgical clipping, given the challenges that exist with current endovascular techniques. We present a case of a large, complex, left middle cerebral artery aneurysm treated with microsurgical clipping. This video highlights critical steps in obtaining proximal and distal control as well as subarachnoid dissection necessary to prepare the aneurysm for final clipping.The video can be found here: http://youtu.be/RlKH2Km9z5Y.

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Comparison of the Efficacy and Safety of Endovascular Coiling Versus Microsurgical Clipping for Unruptured Middle Cerebral Artery Aneurysms: A Systematic Review and Meta-Analysis

World Neurosurgery ◽

10.1016/j.wneu.2015.05.073 ◽

2015 ◽

Vol 84 (4) ◽

pp. 942-953 ◽

Cited By ~ 40

Author(s):

Timothy R. Smith ◽

David J. Cote ◽

Hormuzdiyar H. Dasenbrock ◽

Youssef J. Hamade ◽

Samer G. Zammar ◽

...

Keyword(s):

Systematic Review ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Meta Analysis ◽

Endovascular Coiling ◽

Efficacy And Safety ◽

Microsurgical Clipping ◽

Middle Cerebral Artery Aneurysms

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Microsurgical clipping of middle cerebral artery aneurysms: complications and risk factors for complications

10.21203/rs.3.rs-1048020/v1 ◽

2021 ◽

Author(s):

Thomas METAYER ◽

Arthur Leclerc ◽

Alin Borha ◽

Stephane Derrey ◽

Olivier Langlois ◽

...

Keyword(s):

Risk Factors ◽

Cerebral Ischemia ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Ruptured Aneurysm ◽

Safe Procedure ◽

Neck Size ◽

Microsurgical Treatment ◽

Microsurgical Clipping ◽

Middle Cerebral Artery Aneurysms

Abstract Objective Middle cerebral artery aneurysms (MCAas) with rupture and unruptured IAs are considered good candidates for microsurgery. The objective of the present study was to evaluate the risk of complications and the risk factors for microsurgical treatment of MCAas to better define the indications for microsurgery. Methods We conducted a retrospective cohort study based on data provided from three French tertiary neurosurgical units from January 1, 2013 to May 31, 2020. We first collected data on all the patients who required microsurgical treatment for MCAas. We evaluated the frequency of complications and finally searched for the risk factors for complications after microsurgery. Complications were defined as a composite criterion with the presence of one of the following: procedural-related death, symptomatic cerebral ischemia, impossible exclusion, incomplete exclusion, or (re)bleeding of the treated aneurysm and symptomatic surgical site hematoma. We then compared patients with and without complications using univariate and multivariate analyses. Results Between January 2013 and May 2020, 292 MCAas in 284 patients were treated. A total of 29 (9.9%) MCAas had a complication. The complications were as follows: symptomatic cerebral ischemia: 4.8%, aneurysm rebleeding: 0.3%, surgical site hematoma: 1.0%, impossible exclusion: 0.3%, and incomplete exclusion: 4.1%. However, severe complications, defined as death or a modified Rankin score (mRs) score ≥4 at 3 months, were infrequent and occurred in 7/292 patients (2.4%). In the multivariate analysis, independent risk factors for complications were the following: a ruptured aneurysm, a larger maximum IA size, a larger neck size, and arterial branches passing less than <1 mm from the IA neck or dome. Conclusions MCAa surgery is a safe procedure with a low rate of serious procedure-related complications and an excellent rate of occlusion. The risk factors for complications are a ruptured aneurysm, a larger IA, a larger neck size, and the presence of an “en passage” arterial branch less than 1 mm from the IA. In these cases, at least for factors that do not present a significant difficulty for EVT, such as the presence of an “en passage” artery or ruptured IA, EVT has to be more thoroughly discussed.

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Coiling Versus Microsurgical Clipping in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis

Neurosurgery ◽

10.1093/neuros/nyx623 ◽

2018 ◽

Vol 83 (5) ◽

pp. 879-889 ◽

Cited By ~ 12

Author(s):

Meshal Alreshidi ◽

David J Cote ◽

Hormuzdiyar H Dasenbrock ◽

Michael Acosta ◽

Anil Can ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Meta Analysis ◽

Pooled Analysis ◽

Endovascular Coiling ◽

Neurological Outcomes ◽

Microsurgical Clipping ◽

Unruptured Intracranial Aneurysms ◽

The Status ◽

Middle Cerebral Artery Aneurysms

Abstract BACKGROUND Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo. OBJECTIVE To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis. METHODS A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed. RESULTS Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different. CONCLUSION This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

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Microsurgical Clipping Compared with New and Most Advanced Endovascular Techniques in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis in the Modern Era

World Neurosurgery ◽

10.1016/j.wneu.2019.12.118 ◽

2020 ◽

Vol 137 ◽

pp. 451-464.e1 ◽

Cited By ~ 3

Author(s):

Giada Toccaceli ◽

Francesco Diana ◽

Federico Cagnazzo ◽

Delia Cannizzaro ◽

Giuseppe Lanzino ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Meta Analysis ◽

Endovascular Techniques ◽

Microsurgical Clipping ◽

Middle Cerebral Artery Aneurysms ◽

Modern Era

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Technical nuances of clipping a middle cerebral artery bifurcation aneurysm

Neurosurgical FOCUS ◽

10.3171/2015.7.focusvid.14568 ◽

2015 ◽

Vol 39 (videosuppl1) ◽

pp. V2

Author(s):

Piyush Kalakoti ◽

Shyamal C. Bir ◽

Richard D. Murray ◽

Osama Ahmed ◽

Anil Nanda

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Artery Aneurysm ◽

Middle Cerebral Artery Aneurysm ◽

Postoperative Course ◽

Microsurgical Clipping ◽

Bifurcation Aneurysm ◽

Middle Cerebral Artery Aneurysms ◽

Intraoperative Rupture ◽

Cerebral Artery Aneurysm

Broad-necked middle cerebral artery aneurysms present unique challenges for the vascular neurosurgeon, who must contend with smaller vessels and often a complex clipping strategy. Due to their superficial location, these lesions are still commonly selected for microsurgical clipping. We present a case of a 42-year-old woman with significant vascular disease with a right middle cerebral artery aneurysm. We discuss the key surgical steps, demonstrate the microsurgical dissection and intraoperative rupture encountered and the final clipping strategy, as well as the postoperative course in this operative video presentation.The video can be found here: http://youtu.be/qZ2gvqz7XdQ.

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