gms | German Medical Science

Objective: The results of microsurgical treatment for middle cerebral artery (MCA) aneurysms has been good since decades. Therefore, therapeutic equipoise for MCA aneurysms was rarely considered in the ISAT study, and only few patients with MCA aneurysms were randomized. Nonetheless, after publication of the ISAT study, many institutes switched to a „coil first" policy, resulting in a lack of contemporary surgical MCA aneurysm series despite the fact that vascular microneurosurgery witnessed several technological improvements. Therefore, it was the aim to present the results of MCA aneurysm clipping in a “clip first” institution and to compare the results with current endovascular series.

Method: We performed a retrospective study of a partly retrospective / partly prospective data collection addressing the surgical results of MCA aneurysm clipping, made a literature review of endovascular series and compared the results.

Results: Of 536 patients with ruptured aneurysms, 171 patients (52 men, 118 women, mean age 50.7 years) with a ruptured MCA aneurysm were identified. All patients underwent microsurgical clipping of the ruptured aneurysm. The 30-day-mortality rate was 11 % (n=20) and was related to initially poor Hunt/Hess grade in 16 of the 20 patients (80 %). The rate of good outcome (Glasgow Outcome Scale [GOS] score 4 and 5) was 53.2 % (n=91). The review of the contemporary endovascular literature on MCA aneurysm coiling revealed that the clinical results are mostly inferior and never superior to the presented surgical results.

Conclusions: In the light of our clinical results and the published endovascular series on ruptured MCA aneurysms, a “coil first” policy in ruptured MCA aneurysms is not justified.