Endovascular coil placement compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: a consecutive series

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Object. The goal of this study was to delineate the angioanatomical features that determine whether a patient with an unruptured middle cerebral artery (MCA) aneurysm is treated using endovascular coil placement or surgical clipping.

Methods. Thirty consecutive patients harboring 34 unruptured MCA aneurysms were evaluated. Patients with unruptured aneurysms are managed prospectively according to the following protocol: the primary treatment recommendation is endovascular packing with Guglielmi detachable coils (GDCs). Surgical clipping is recommended after failed attempts at coil placement or in the presence of angioanatomical features that contraindicate that type of endovascular therapy.

Of 34 unruptured MCA aneurysms, two (6%) were successfully embolized and 32 (94%) were clipped. Of these 32 surgically treated aneurysms, in 11 (34%) an attempt at GDC embolization had failed, whereas in 21 (66%) primary clipping was performed because of unfavorable angioanatomy. Of the 13 aneurysms treated endovascularly, two (15%) were successfully excluded, whereas GDC treatment failed in 11 (85%). An unfavorable dome/neck ratio (< 2) and an arterial branch originating at the aneurysm base were the reasons for embolization failure.

Conclusions. Careful evaluation of the angioanatomy of unruptured aneurysms allows selection of the most appropriate treatment. However, for unruptured MCA aneurysms, surgical clipping appears to be the most efficient treatment option. Series of unruptured aneurysms are ideal for comparing treatment results.

Article Information

Address reprint requests to: Luca Regli, M.D., Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland. email: Luca.Regli@chuv.hospvd.ch.

© AANS, except where prohibited by US copyright law.

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Figures

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    Supraselective aneurysmographic studies obtained before (left) and after (center and right) coil placement in an unruptured 15-mm MCA bifurcation aneurysm that was successfully treated using GDCs. The aneurysm dome/neck ratio was 3.75, which is favorable for endovascular occlusion of the dome.

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    Left: Supraselective aneurysmographic studies obtained before endovascular treatment of an unruptured 8-mm MCA bifurcation aneurysm. The dome/neck ratio was 3, but the origin of the frontoopercular trunk was partially incorporated into the aneurysm base (arrow). Right: Aneurysmographic studies showing that the aneurysm dome packing is complete, but subtotal occlusion of the frontoopercular trunk is also apparent (arrowheads). The cortical collateral vessels were well developed and the patient did not suffer a stroke.

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    Digital subtraction angiographic study revealing an unruptured 4-mm M1 segment MCA aneurysm with a dome/neck ratio of 1.5 or smaller and a temporal branch originating from the aneurysm base. Endovascular treatment was attempted despite the unfavorable angioanatomical features. The GDCs did not stabilize within the aneurysm dome and protruded into the arterial lumen (arrow). Endovascular treatment was therefore aborted and the aneurysm was successfully clipped.

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    Subtraction ICA angiographic and aneurysmographic studies revealing an unruptured 10-mm MCA bifurcation aneurysm. The aneurysmographic studies revealed that the origin of the inferior M2 trunk was not distinct from the aneurysm base. The attempt at embolization was therefore abandoned and the MCA bifurcation aneurysm was successfully clipped. This patient had already undergone successful embolization of a ruptured basilar artery tip aneurysm (arrows).

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