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Ideal clipping methods for unruptured middle cerebral artery bifurcation aneurysms based on aneurysmal neck classification

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Abstract

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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Acknowledgments

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.

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No funds were received in support of this work.

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Authors and Affiliations

  1. Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 150, Seongan-ro, Gangdong-gu, Seoul, 134-701, Republic of Korea

    Hong Jun Jeon

  2. Department of Neurosurgery, Severance Hospital, Stroke Center, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemon-gu, Seoul, 120-752, Republic of Korea

    So Yeon Kim, Keun Young Park, Jae Whan Lee & Seung Kon Huh

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  1. Hong Jun Jeon
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  2. So Yeon Kim
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Correspondence to Jae Whan Lee.

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Comments

Andrew F. Ducruet, Pittsburgh, Pennsylvania

The authors present a large series of unruptured MCA bifurcation aneurysms treated by microsurgical clipping. They derive an anatomic classification system in an effort to standardize the clipping method for these lesions. Obviously, not every lesion will fit soundly into their proposed classification scheme, and ultimately, each surgeon must rely on their own judgment and experience. The concept that intraoperative findings are necessary to accurately determine the true neck of these lesions is of particular interest. This highlights one of the limitations of digital subtraction angiography in defining the neck anatomy and its relationship to the parent vessel in this location and may explain in part the difficulty of treating these lesions endovascularly. The authors should be congratulated on their significant contribution to the existing cerebrovascular literature.

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Jeon, H.J., Kim, S.Y., Park, K.Y. et al. Ideal clipping methods for unruptured middle cerebral artery bifurcation aneurysms based on aneurysmal neck classification. Neurosurg Rev 39, 215–224 (2016). https://doi.org/10.1007/s10143-015-0671-x

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  • DOI: https://doi.org/10.1007/s10143-015-0671-x

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