Diagnostic reliability of the Berlin classification for complex MCA aneurysms-usability in a series of only giant aneurysms.

BACKGROUND AND OBJECTIVE: The main challenge of bypass surgery of complex MCA aneurysms is not the selection of the bypass type but the initial decision-making of how to exclude the affected vessel segment from circulation. To this end, we have previously proposed a classification for complex MCA aneurysms based on the preoperative angiography. The current study aimed to validate this new classification and assess its diagnostic reliability using the giant aneurysm registry as an independent data set. METHODS: We reviewed the pretreatment neuroimaging of 51 patients with giant (> 2.5 cm) MCA aneurysms from 18 centers, prospectively entered into the international giant aneurysm registry. We classified the aneurysms according to our previously proposed Berlin classification for complex MCA aneurysms. To test for interrater diagnostic reliability, the data set was reviewed by four independent observers. RESULTS: We were able to classify all 51 aneurysms according to the Berlin classification for complex MCA aneurysms. Eight percent of the aneurysm were classified as type 1a, 14% as type 1b, 14% as type 2a, 24% as type 2b, 33% as type 2c, and 8% as type 3. The interrater reliability was moderate with Fleiss's Kappa of 0.419. CONCLUSION: The recently published Berlin classification for complex MCA aneurysms showed diagnostic reliability, independent of the observer when applied to the MCA aneurysms of the international giant aneurysm registry.

Endovascular treatment of middle cerebral artery aneurysms - single-centre results.

PURPOSE: The middle cerebral artery (MCA) is the second most common location of intracerebral aneurysms. Traditionally, they are treated by microsurgical clipping, but with the development of new techniques and devices endovascular embolisation is gaining more importance. The aim of this study was to summarise six years of experience of our department in endovascular treatment of MCA aneurysms. MATERIAL AND METHODS: Forty patients with 41 MCA aneurysms treated in a single centre were included in this study. Data on patients' comorbidities, aneurysm morphology, and treatment course were collected, with special emphasis on complications. RESULTS: There were no statistically significant differences in terms of aneurysm morphology between males and females and between ruptured and unruptured aneurysms. None of the diseases analysed in the current study were linked with significantly increased risk of SAH. Unruptured aneurysms were significantly more frequently treated by stent-assisted coiling (30.4% vs. 5.6%, p = 0.0388) than were ruptured aneurysms, while ruptured aneurysms were treated more frequently by coiling alone (77.8% vs. 34.8%, p = 0.0062). After an initial course of treatment 63.4% (n = 26) of patients had class I in Raymond-Roy occlusion classification, 22% (n = 9) had class II, and 14.6% (n = 6) had class III. Complications of the procedure were observed in 17.5% (n = 7) of patients: 22.2% (n = 4) with ruptured and 13.6% (n = 3) with unruptured aneurysms. CONCLUSIONS: Endovascular treatment of MCA aneurysms is feasible, and our results are convergent with other studies. Ruptured MCA aneurysms may be treated endovascularly with similar effects as unruptured MCA aneurysms. The complication rate of such treatment is low.

Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms.

OBJECTIVEThe rapid innovation of the endovascular armamentarium results in a decreased number of indications for a classic surgical approach. However, a middle cerebral artery (MCA) aneurysm remains the best example of one for which results have favored microsurgery over endovascular intervention. In this study, the authors aimed to evaluate the experience and efficacy regarding surgical outcomes after applying internal maxillary artery (IMA) bypass for complex MCA aneurysms (CMCAAs).METHODSAll IMA bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice were screened.RESULTSIn total, 12 patients (9 males, 3 females) with CMCAAs managed by high-flow IMA bypass were identified. The mean size of CMCAAs was 23.7 mm (range 10-37 mm), and the patients had a mean age of 31.7 years (range 14-56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2-74 months) and 53.1 months (range 19-82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.CONCLUSIONSThe satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm.

[Rupture of a giant aneurysm of the accessory middle cerebral artery: a case report and a literature review]. / Razryv gigantskoi chastichno trombirovannoi anevrizmy dobavochnoi srednei mozgovoi arterii: sluchai iz praktiki i obzor literatury.

The accessory middle cerebral artery is a rare congenital vascular abnormality. The international literature has reported cases of accessory MCA aneurysms. In this article, we describe a case of rupture of a giant partially thrombosed aneurysm of the accessory MCA. This case is of great interest due to rarity of the pathology and associated diagnostic errors.

High flow EC-IC bypass for a giant left MCA aneurysm.

Giant cerebral aneurysms may be treated through a variety of options, including aneurysm trapping with concurrent bypass. This video describes the case of a large, recurrent, left middle cerebral artery aneurysm that was treated using a high flow, radial artery bypass graft, from the external carotid artery to the left temporal M2 branch. A step-by-step operative description, with emphasis on proper microsurgical technique, is included. The video can be found here: http://youtu.be/9xTMC6InivQ .

Virtual reality guided focused Sylvian approach for clipping unruptured middle cerebral artery aneurysms.

Objective: The increasing prevalence of unruptured intracranial aneurysms, detected through advanced brain imaging, necessitates a cautious approach to surgical intervention, with a focus on minimizing associated risks. This retrospective study explores the safety and better aesthetic outcomes of a Virtual Reality (VR) guided Focused Sylvian Approach (FSA) in comparison to the standard Pterional Surgical Approach (SPA) for the clipping of unruptured small-medium-size (<10 mm) Middle Cerebral Artery (MCA) aneurysms. Methods: 23 patients with 23 unruptured MCA aneurysms underwent the VR-guided FSA from June 2020 to September 2023, while 22 patients with 23 unruptured MCA aneurysms who underwent SPA were retrospectively recruited from the medical records database from January 2017 to May 2020. The comparative analysis involved surgical duration, postoperative complications, hospital stay, and a three-month follow-up patient's sequela survey. Results: All aneurysms were effectively treated. The FSA procedure demonstrated a shorter surgical duration compared to the SPA group (164 ± 48 min vs. 196 ± 133 min, P = 0.2974). Despite a slightly higher median age in the FSA group (59 vs. 56 years), the median hospital stay was shorter in the FSA group (6 days) compared to the SPA group (7 days). The SPA group exhibited a higher incidence of complications (17/23) including cephalalgia, scar irritation, scar numbness, and temporal muscle dysfunction, compared to the FSA group (1/23), with a statistical significance of P < 0.05. Although FSA cannot demonstrate significant surgical efficiency in surgical duration and hospitalization, its superior aesthetics and preservation of temporalis muscle function compared to the SPA group. Conclusion: The VR-guided FSA offers improved aesthetics and preservation of muscle function compared to the SPA. Our retrospective study underscores the potential benefits of VR-guided, personalized, focused Sylvian approaches for managing unruptured small-medium-size MCA aneurysms.

Endovascular treatment of middle cerebral artery aneurysms: current status and future prospects.

Middle cerebral artery (MCA) aneurysms are complex and widely distributed throughout the course of the MCA. Various types of aneurysms can occur in the MCA. Ruptured as well as unruptured MCA aneurysms may require treatment to avoid bleeding or rebleeding. Currently, clipping is regarded as the first-line choice for the treatment of MCA aneurysms. However, endovascular treatment (EVT) is emerging as an alternative treatment in selected cases. EVT techniques vary. Therefore, it is necessary to review EVT for MCA aneurysms. In this review, the following issues were discussed: MCA anatomy and anomalies, classifications of MCA aneurysms, the natural history of MCA aneurysms, EVT status and principle, deployments of traditional coiling techniques and flow diverters (FDs), and deployments and prospects of intrasaccular flow disruptors and stent-like devices. According to the review and our experience, traditional coiling EVT is still the preferred therapy for most MCA aneurysms. FD deployment can be used in selective MCA aneurysms. Parent artery occlusion (PAO) can be used to treat distal MCA aneurysms. In addition, new devices can be used to treat MCA aneurysms, such as intrasaccular flow disruptors and stent-like devices. In general, EVT is gaining popularity as an alternative treatment option; however, there is still a lack of evidence regarding EVT, and longer-term data are not currently available for most EVT devices.

Microsurgical Clipping of a Middle Cerebral Artery Aneurysm After Woven Endobridge Embolization Recurrence.

We present the case of a 67-year-old patient with a left middle cerebral artery (MCA) aneurysm treated with a Woven EndoBridge (WEB) device, who experienced neck recurrence after initial complete obliteration. The initial angiogram showed a wide-necked left MCA aneurysm that measured 8 × 7 mm with a 5-mm neck, treated with a WEB device. Post implantation, the initial follow-up angiogram showed complete obliteration. However, subsequent angiogram showed neck recurrence measuring 6.6 × 1.7 mm. The WEB device has become a popular alternative to traditional clipping and coiling procedures, with studies reporting successful treatment of 85%. However, concerns have been raised regarding the device's efficacy in achieving complete aneurysm obliteration, with a lower rate of complete aneurysm occlusion and a higher rate of recurrence compared with surgical clipping. The decision was made to retreat with clipping, and the surgery was successful in completely obliterating the aneurysm. The patient had no residual MCA aneurysm, with both M2 branches patent on postoperative angiogram. Literature review of retreatment options for WEB device failures highlights that the retreatment rate after WEB embolization is approximately 10%. For surgically accessible aneurysms, surgical clipping is an effective retreatment strategy after WEB failure given the compressibility of the device. Video 1 and our literature review provide valuable insights into a rare case of aneurysm recurrence after complete obliteration at initial follow-up after WEB embolization that was successfully treated with surgical clipping.1-8.

Middle Cerebral Artery Aneurysm Trial (MCAAT): A Randomized Care Trial Comparing Surgical and Endovascular Management of MCA Aneurysm Patients.

BACKGROUND: Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS: The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multicenter, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is "Treatment Success": (i) occlusion or exclusion of the aneurysm using the allocated treatment modality; (ii) no intracranial hemorrhage during follow-up; (iii) no retreatment of the target aneurysm during follow-up, (iv) no residual aneurysm on angiographic follow-up; and (v) independence (mRS <3) at 1 year. The trial tests 2 versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared with endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1-year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSIONS: Patients with MCA aneurysms can be optimally managed within a care trial protocol.

The sylvian keyhole approach for surgical clipping of middle cerebral artery aneurysms: Technical nuance to the minipterional craniotomy.

Background: The minipterional (MPT) craniotomy is a workhorse approach for clipping of middle cerebral artery (MCA) aneurysms. Because it aims to reach the skull base, traction on the temporal muscle is required. As a result, patients may suffer from transient postoperative temporal muscle discomfort. The sylvian keyhole approach (SKA) represents an alternative craniotomy for the clipping of MCA aneurysms. The aims of this study are to describe the operative technique of the SKA and to discuss the benefits and disadvantages compared to the MPT craniotomy. Methods: In this technical note, we report the experience gained with the SKA. This experience was acquired with virtual reality, 3D-printed models, and anatomical dissections. We also present two clinical cases. Results: The SKA is centered on the distal sylvian fissure and tailored toward the specific MCA aneurysm. Traction to the temporal muscle is not necessary because access to the skull base is not sought. With the SKA, dissection of the MCA is performed from distal to proximal, aiming for a proximal control at the level of the M1-segment. The limen insulae was identified as a key anatomical landmark for approach selection. The SKA offers good surgical maneuverability when the aneurysm is located at the level or distal to the limen. The MPT craniotomy, however, remains the most appropriate approach when the aneurysm is located proximal to the limen. Conclusion: The SKA represents a feasible and innovative alternative approach to the MPT craniotomy for surgical clipping of unruptured MCA aneurysms located at the level or distal to the limen insulae.

Ruptured Distal Middle Cerebral Artery Aneurysms-Characteristics and Strategy.

BACKGROUND: Distal middle cerebral artery (dMCA) aneurysms are very rare. Most ruptured dMCA aneurysms lead to subarachnoid hemorrhage (SAH) coexisting with intracerebral hematoma (ICH), resulting in a deteriorating state. The risk factors of rupture of dMCA aneurysms remain unknown. To elucidate the risk of rupture, we studied differences between 4 ruptured and eleven unruptured dMCA aneurysms. METHODS: We retrospectively analyzed patients diagnosed with a dMCA aneurysm according to the maximum size of the aneurysm, aspect ratio, and aneurysm size to vessel size (size ratio). RESULTS: Four patients presented with SAH coexisting with ICH, resulting in a midline shift, caused by rupture of the dMCA aneurysm. The median aspect ratio of ruptured and unruptured dMCA aneurysms was 2.38 and 1.65, respectively, with no significant difference. The median maximum diameter of ruptured and unruptured dMCA aneurysms was 2.98 and 3.78 mm, respectively, with nonsignificant difference. The median size ratio of ruptured and unruptured dMCA aneurysms was 3.13 and 1.84, respectively, being significant difference (P < 0.02). The outcomes of 4 patients having ruptured dMCA aneurysm were as follows: one patient died due to the initial attack, and the others were severely disabled due to cerebral infarction caused by vasospasm. CONCLUSIONS: Distal MCA aneurysms, even if they are small, may be likely to rupture leading to SAH complicated by ICH and result in a poor neurological state and unfavorable outcomes. We recommend aggressive treatment for dMCA aneurysms considering morphological factors such as the size ratio even if they are small and unruptured.

Early Exposure of the Dorsal Surface of M1 Segment via the Distal Transsylvian Approach for Clipping of Anteroinferior-Projecting Middle Cerebral Artery Bifurcation Aneurysms.

Background Middle cerebral artery bifurcation (MCAB) aneurysms are common intracranial aneurysms. Anteroinferior-projecting MCAB aneurysms, with M1 segment usually embedded into the deep part of the Sylvian fissure, cause some surgical challenges. The distal transsylvian approach (DTSA) allows M1 exposure from the dorsal surface for proximal control in the early step. Therefore, this study aimed to demonstrate the efficacy and safety of DTSA for clipping anteroinferior-projecting MCAB aneurysms. Methods Among 97 patients with MCA aneurysms, 13 with anteroinferior-projecting MCAB aneurysms who underwent aneurysm clipping via the DTSA between June 2018 and January 2021 were retrospectively evaluated for the aneurysm obliteration rate, surgical complications, and outcomes. Results Ten patients (76.9%) had ruptured MCAB aneurysms and three (23.1%) had incidentally discovered unruptured MCAB aneurysms. Favorable outcome was achieved in 100% of patients with good grade. The complete aneurysm obliteration rate was 100% without intraoperative lenticulostriate artery injury. Twelve (92.3%) patients had early identified distal M1 segment for proximal control, and one (7.7%) patient had premature rupture of aneurysm that achieved favorable outcome at 3 months postoperatively. Difficult M1 exposure and premature rupture occurred in the patient with MCAB located above the Sylvian fissure line. Permanent postoperative neurological deficit was detected in one patient due to severe vasospasm. Conclusion DTSA, which simplify the early exposure of the dorsal surface of distal M1, is safe and effective for clipping anteroinferior-projecting MCAB aneurysms without extensive Sylvian fissure dissection. High-positioned MCAB requires careful dissection of the aneurysm neck with consideration of tentative clipping preparation.

Clip Reconstruction of Recurrent, Previously Coiled MCA Aneurysm with M2-M2 Side-Side Reimplantation.

Fourth-generation bypass techniques are novel constructs that may be useful when standard bypass methods fail.1-3 They involve the use of an unconventional (i.e., intraluminal) suturing technique (type 4A) or vascular orientation (type 4B).4 We report the use of a type 4B fourth-generation reimplantation bypass for treatment of a recurrent middle cerebral artery (MCA) aneurysm. A woman in her mid-60s presented with recurrence of a previously treated unruptured MCA aneurysm. Her aneurysm was partially coiled, and recurrence developed at the base of the coil mass. Informed consent was obtained from the patient. The MCA bifurcation was exposed with a pterional-transsylvian approach (Video 1). The aneurysm fundus was mobilized to visualize the origin at the bifurcation between the middle and frontal trunk of the MCA. Clip reconstruction was attempted via a "picket-fence" technique.5 Indocyanine green videoangiography revealed occlusion of the middle trunk. The middle trunk was transected and reimplanted to the frontal trunk in end-side fashion, with intraluminal suturing (type 4A bypass). Indocyanine green videoangiography showed no flow because of endothelial damage from the endovascular therapy. The middle trunk was transected off the frontal trunk and diverted to the temporal trunk, where a type 4B side-to-side reimplantation bypass was performed using a longer arteriotomy to maximize the anastomotic area. Patency and aneurysm occlusion were confirmed with Yellow 560 fluorescence. The patient tolerated the procedure well, and no postoperative neurologic deficits were noted. The fourth-generation bypass concepts allow the surgeon to conceive atypical constructs, which are especially useful for troubleshooting challenging revascularization scenarios.3.

Surgical Resection and Clipping of an Atherosclerotic Partially Calcified Middle Cerebral Artery Trifurcation Aneurysm with Clipping of an Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

It is estimated within the western population that 10%-13% of patients possess multiple intracranial aneurysms1 and are linked to certain risk factors. Thrombotic aneurysms are a rare subgroup of complex aneurysms characterized by an organized intraluminal thrombus.2,3 They differ from typical saccular aneurysms in terms of morphology, natural history, symptomatology, and difficulty in treatment with conventional strategies.2,4 The risk of rupture is poorly characterized and assumed to be comparable with that of nonthrombotic aneurysms.2 A subset of thrombotic aneurysms can be treated surgically with conventional clipping, and direct clipping has been associated with the best surgical outcome.2 Despite its safety, endovascular treatment is associated with a high risk of recurrence and retreatment compared with surgical treatment,5 with recanalization rates up to 5× higher compared with nonthrombosed aneurysms.6,7 A 64-year-old male presented with headaches and dizziness for 6 months. He was neurologically intact. Imaging revealed a calcified thrombosed right middle cerebral artery aneurysm and an anterior communicating artery aneurysm, both of which underwent clipping. The patient consented to the procedure. Preservation of blood flow in branch arteries in thrombosed aneurysms is challenging. Thrombectomy and clip reconstruction in such cases can occlude the branch vessels, compromising blood flow. Achieving adequate proximal control and meticulous dissection of the branches is necessary before reconstruction. We present a 2-dimensional video demonstrating the surgical steps of clipping and reconstruction of the giant thrombosed middle cerebral artery aneurysm. Complete occlusion was achieved, and the patient tolerated the operation well with an uneventful postoperative course.

Surgical Trapping of a Large Complex Middle Cerebral Artery Aneurysm With Double-Barrel Bypass: 3-Dimensional Operative Video.

Large middle cerebral artery (MCA) bifurcation aneurysms are known vascular lesions that are usually symptomatic but often difficult to treat (whether with open or endovascular techniques), especially when the M2 branches originate from the aneurysm dome.1-7 The challenge lies in securing the aneurysm while fully maintaining the flow in the vessels arising from the dome. Standard microsurgical clipping or endovascular techniques are not feasible in perfectly treating these aneurysms. Revascularization of the MCA branches with bypass and trapping of the aneurysm is often necessary. Here, we present a case of a large complex partially thrombosed right MCA bifurcation aneurysm with both the superior and the inferior divisions arising from the dome. The patient initially presented with a right MCA stroke and left hemiparesis. Using radial artery as an interposition graft, 2 bypasses-internal maxillary artery to the inferior division and superficial temporal artery to the superior division-were performed. The aneurysm was trapped and decompressed by placing clips at the M1 terminus and the M2 origins. Intraoperative angiography and postoperative NOVA (VasSol Inc.) magnetic resonance angiography (MRA) confirmed patency and excellent flow in the bypass grafts. The patient's postoperative course was uncomplicated, and at 2-mo follow-up, had significant improvement of her hemiparesis. The patient provided informed consent for the procedure.

Clip Ligation of Midsegment M1 Artery Aneurysm through a Lateral Supraorbital Approach: 2-Dimensional Operative Video.

Lenticulostriate middle cerebral artery (MCA) aneurysms are rare and often involve perforating vessels, making endovascular treatment difficult. When projecting superiorly, aneurysm rupture can likely cause intraparenchymal hemorrhage in basal ganglia. Consequently, surgical clip ligation requires control not to aggressively elevate the frontal lobe to avoid intraoperative injury. We report a case of a growing right midsegment MCA aneurysm treated with clip ligation via a lateral supraorbital approach (LSO). The patient is a 71-year-old female found to have a 4 mm × 3 mm right M1 aneurysm in 2014 on workup for headaches. Subsequent imaging demonstrated aneurysm growth to 6 mm × 3.1 mm with peaked-dome appearance. The growth and location of the aneurysm led us to recommend open surgical treatment; the patient provided informed written consent to proceed. We performed a standard right-sided LSO approach.1 Microdissection was performed to split the sylvian fissure distally and then proximally to expose the MCA on either side of the aneurysm. Dissecting the aneurysm revealed a perforating artery at the proximal neck. Using minimal frontal lobe dynamic retraction, microsurgical clip ligation was performed. We ensured the clip was placed in line with the MCA trunk to avoid kinking the parent artery and subsequent stroke. Intraoperative micro-Doppler and indocyanine green injection confirmed the patency of vasculature. Postoperative angiogram confirmed complete aneurysm ligation. The patient clinically did well and was discharged home on postoperative day 2. Our video demonstrates safe and effective surgical treatment of a rare aneurysm2 through a small LSO craniotomy approach (Video 1).

Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison.

OBJECTIVE: There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. METHODS: Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. RESULTS: There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling. CONCLUSIONS: Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.

Combined Internal Maxillary Artery to Middle Cerebral Artery and In Situ Middle Cerebral to Middle Cerebral Artery Bypass for Complex Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

Flow-replacement revascularization and/or flow augmentation surgery may be necessary for safe deconstruction of complex middle cerebral artery (MCA) aneurysms. Roughly 1% to 2% of all MCA aneurysms have angiographic features prohibiting standard microsurgical or endovascular management. Consent was obtained from the patient for the production of this video. No International Review Board approval was required for the creation of this video. A 17-yr-old female presented at the age of 15 with headaches. At the time of initial presentation, the patient was found to have an MCA bifurcation aneurysm. Initially, the aneurysm was managed conservatively and followed. However, on follow-up imaging, the aneurysm was found to have grown and developed into a large, complex MCA bifurcation aneurysm. Patient underwent planned trapping and deconstruction of the aneurysm. An internal maxillary artery (IMAX) to MCA bypass was performed using a cephalic vein graph to a robust inferior MCA branch combined with an in Situ MCA to MCA bypass. Follow-up angiography showed complete occlusion of the aneurysm. Patient was neurologically intact at 1-yr follow-up. Microsurgery continues to be the best treatment option for complex MCA aneurysms. A surgeon trained in bypass is an absolute prerequisite for management of those lesions. The IMAX offers an ideal high flow donor vessel for subcranial to intracranial flow replacement, which was required for re-establishment of flow to the robust inferior MCA branch in this case. The superior branch of the MCA was less robust. Therefore, by recreating a more distal bifurcation, the in Situ side-to-side MCA-MCA bypass simplified the revascularization strategy.

Rescue Maneuver for Dislocated Woven EndoBridge Device in Middle Cerebral Artery.

BACKGROUND: Intrasaccular flow disruption has emerged as a useful modality for treatment of wide-necked saccular aneurysm at vessel bifurcations. The Woven EndoBridge (WEB) device is one such device that has been evaluated in several series with excellent safety and good midterm efficacy. Bailout techniques to retrieve or reposition a dislocated WEB device are sparse and associated with significant risks. We describe a case of a dislocated WEB device that was repositioned with a microcatheter alone. METHODS: We describe a case of a WEB device that inadvertently detached in the parent vessel and the technique we used to reposition it. A number of bailout techniques are discussed with pros and cons associated with each maneuver. RESULTS: An unruptured middle cerebral artery (MCA) aneurysm was treated by endovascular embolization with a WEB device. The WEB was deployed within the aneurysm without incident. However, the device failed to detach. While attempting to resheath the device, it extruded out of the aneurysm and then inadvertently detached in the MCA. After many options were considered, a microcatheter alone was used to push the device back into the aneurysm. CONCLUSION: Caution should be exercised, especially when detaching the WEB device. Microcatheter repositioning by pushing the dislocated device may be attempted, especially if part of the device is within the aneurysm. This is the first description of the described microcatheter repositioning rescue maneuver.

Patterns of care for ruptured aneurysms of the middle cerebral artery: analysis of a Swiss national database (Swiss SOS).

OBJECTIVE: The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort. METHODS: The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009-2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined. RESULTS: Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74-1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89-12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23-2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30-0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676). CONCLUSIONS: Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.