Endovascular coiling is widely used for many cerebral aneurysms; however, in cases of middle cerebral artery bifurcation (MCBIF) aneurysms, it is associated with a higher incidence of unfavorable outcomes compared to microsurgical clippings. In this retrospective study, we aimed to investigate the outcomes of microsurgical clipping for unruptured MCBIF aneurysms and determine the ideal clipping methods for different aneurysm subtypes. From January 2011 to December 2013, 203 aneurysms with saccular shape (<25 mm) were treated by an experienced neurosurgeon. Depending on the involvement of the aneurysmal thin wall, the aneurysm neck was classified as follows: subtype I, limited bifurcation; subtype II, progressed to M1 trunk; subtype III, progressed to M2 trunk; subtype IV, progressed to M1 and one M2 trunk; and subtype V, progressed to M1 and two M2 trunks. The clipping methods included simple, sliding, interlocking, or mixed approaches. Aneurysm clippings were accomplished without any morbidity in all cases, and seven cases had a minimal neck remnant. The following clipping methods were predominantly used: subtype I, simple (90.2 %) and sliding (8.8 %) (mean = 1.2 clips); subtype II, interlocking (51.4 %), sliding (30.0 %), mixed (15.7 %), and simple (2.9 %) (2.4 clips); subtype III, simple (57.5 %) and sliding (42.5 %) (1.5 clips); subtype IV, interlocking (64.3 %) (2.1 clips), simple (10.7 %), sliding (14.3 %), and mixed (10.7 %); and subtype V, interlocking (50.0 %), sliding (35.7 %), and mixed (14.3 %) methods with multiple clips (2.8 clips). If an appropriate clipping method is selected according to the neck classification, satisfactory surgical obliteration can be achieved for unruptured MCBIF aneurysms without morbidity.
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The authors would like to thank Dong-Su Jang, MFA (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his help with the illustrations.
Conflict of interest
No funds were received in support of this work.
Aghakhani N, Vaz G, David P, Parker F, Goffette P, Ozan A, Raftopoulos C (2008) Surgical management of unruptured intracranial aneurysms that are inappropriate for endovascular treatment: experience based on two academic centers. Neurosurgery 62(6):1227–1234, discussion 1234-1225CrossRefPubMedGoogle Scholar
Clatterbuck RE, Galler RM, Tamargo RJ, Chalif DJ (2006) Orthogonal interlocking tandem clipping technique for the reconstruction of complex middle cerebral artery aneurysms. Neurosurgery 59(4 Supplmt 2):ONS347-351; discussion ONS351-342Google Scholar
Dashti R, Hernesniemi J, Niemela M, Rinne J, Porras M, Lehecka M, Shen H, Albayrak BS, Lehto H, Koroknay-Pal P, de Oliveira RS, Perra G, Ronkainen A, Koivisto T, Jaaskelainen JE (2007) Microneurosurgical management of middle cerebral artery bifurcation aneurysms. Surg Neurol 67(5):441–456CrossRefPubMedGoogle Scholar
David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S (1999) Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 91(3):396–401CrossRefPubMedGoogle Scholar
Feuerberg I, Lindquist C, Lindqvist M, Steiner L (1987) Natural history of postoperative aneurysm rests. J Neurosurg 66(1):30–34CrossRefPubMedGoogle Scholar
Fields JD, Brambrink L, Dogan A, Helseth EK, Liu KC, Lee DS, Nesbit GM, Petersen BD, Barnwell SL (2013) Stent assisted coil embolization of unruptured middle cerebral artery aneurysms. J Neurointerv Surg 5(1):15–19CrossRefPubMedGoogle Scholar
Investigators C (2006) Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment. Stroke 37(6):1437–1442CrossRefGoogle Scholar
Ishikawa T, Nakayama N, Moroi J, Kobayashi N, Kawai H, Muto T, Yasui N (2009) Concept of ideal closure line for clipping of middle cerebral artery aneurysms--technical note. Neurol Med Chir (Tokyo) 49(6):273–277, discussion 277-278CrossRefGoogle Scholar
Kim BM, Kim DI, Park SI, Kim DJ, Suh SH, Won YS (2011) Coil embolization of unruptured middle cerebral artery aneurysms. Neurosurgery 68(2):346–353, discussion 353-344CrossRefPubMedGoogle Scholar
Kim BM, Kim DJ, Kim DI, Park SI, Suh SH, Won YS (2010) Clinical presentation and outcomes of coil embolization of remnant or recurred intracranial aneurysm after clipping. Neurosurgery 66(6):1128–1133, discussion 1133CrossRefPubMedGoogle Scholar
Kumar MV, Karagiozov KL, Chen L, Imizu S, Yoneda M, Watabe T, Kato Y, Sano H, Kanno T (2007) A classification of unruptured middle cerebral artery bifurcation aneurysms that can help in choice of clipping technique. Minim Invasive Neurosurg 50(3):132–139CrossRefPubMedGoogle Scholar
Lawton M (2011) Seven aneurysms: tenets and techniques for clipping. Thieme, New York, pp 72–73Google Scholar
Lin T, Fox AJ, Drake CG (1989) Regrowth of aneurysm sacs from residual neck following aneurysm clipping. J Neurosurg 70(4):556–560CrossRefPubMedGoogle Scholar
Lubicz B, Leclerc X, Gauvrit JY, Lejeune JP, Pruvo JP (2004) HyperForm remodeling-balloon for endovascular treatment of wide-neck intracranial aneurysms. AJNR Am J Neuroradiol 25(8):1381–1383PubMedGoogle Scholar
Mizutani T, Kojima H (2000) Clinicopathological features of non-atherosclerotic cerebral arterial trunk aneurysms. Neuropathology 20(1):91–97CrossRefPubMedGoogle Scholar
Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P, International Subarachnoid Aneurysm Trial Collaborative G (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366(9488):809–817CrossRefPubMedGoogle Scholar
Morgan MK, Mahattanakul W, Davidson A, Reid J (2010) Outcome for middle cerebral artery aneurysm surgery. Neurosurgery 67(3):755–761, discussion 761CrossRefPubMedGoogle Scholar
Niskanen M, Koivisto T, Rinne J, Ronkainen A, Pirskanen S, Saari T, Vanninen R (2005) Complications and postoperative care in patients undergoing treatment for unruptured intracranial aneurysms. J Neurosurg Anesthesiol 17(2):100–105CrossRefPubMedGoogle Scholar
Nussbaum ES, Madison MT, Myers ME, Goddard J (2007) Microsurgical treatment of unruptured intracranial aneurysms. A consecutive surgical experience consisting of 450 aneurysms treated in the endovascular era. Surg Neurol 67(5):457–464, discussion 464-456CrossRefPubMedGoogle Scholar
Osborn A (1999) Diagnostic Cerebral Angiography, 2nd edn. Lippincott Williams & Wilkins, Philadelphia, pp 135–151Google Scholar
Quadros RS, Gallas S, Noudel R, Rousseaux P, Pierot L (2007) Endovascular treatment of middle cerebral artery aneurysms as first option: a single center experience of 92 aneurysms. AJNR Am J Neuroradiol 28(8):1567–1572CrossRefPubMedGoogle Scholar
Rabinstein AA, Nichols DA (2002) Endovascular coil embolization of cerebral aneurysm remnants after incomplete surgical obliteration. Stroke 33(7):1809–1815CrossRefPubMedGoogle Scholar
Rinne J, Hernesniemi J, Niskanen M, Vapalahti M (1996) Analysis of 561 patients with 690 middle cerebral artery aneurysms: anatomic and clinical features as correlated to management outcome. Neurosurgery 38(1):2–11CrossRefPubMedGoogle Scholar
Rodriguez-Hernandez A, Sughrue ME, Akhavan S, Habdank-Kolaczkowski J, Lawton MT (2013) Current management of middle cerebral artery aneurysms: surgical results with a “clip first” policy. Neurosurgery 72(3):415–427CrossRefPubMedGoogle Scholar
Sindou M, Acevedo JC, Turjman F (1998) Aneurysmal remnants after microsurgical clipping: classification and results from a prospective angiographic study (in a consecutive series of 305 operated intracranial aneurysms). Acta Neurochir (Wien) 140(11):1153–1159CrossRefGoogle Scholar