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Results of endovascular treatment of middle cerebral artery aneurysms after first giving consideration to clipping

  • Clinical Article - Neurosurgical Techniques
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Abstract

Background

Middle cerebral artery (MCA) aneurysms are among the more challenging aneurysms for endovascular treatment. We report a contemporary 5-year experience with endovascular therapy for MCA aneurysms at a high-volume neurovascular center.

Methods

Review of prospectively maintained intracranial aneurysm database.

Results

Between 2005 and 2009, 148 patients underwent treatment of 149 MCA aneurysms at our hospital, of which 33 patients with 34 aneurysms underwent endovascular therapy. Among these 33 patients, 14 presented with subarachnoid hemorrhage. Eleven patients were treated with stent-assisted coiling, 1 with balloon-assisted coiling, and the remainder with coiling alone. Three patients required repeat endovascular treatment. There were 7 periprocedural complications, including intraprocedural aneurysm rupture resulting in death in 2 patients. Two patients died at later dates from remote aneurysm rehemorrhage. Average follow-up of remaining patients was 17.1 months radiographically, and 20.3 months clinically. Average modified Rankin scale (mRS) score at last follow up was 2.09, with 17 patients with mRS 0/1 and 5 patients with mRS 2. Fifteen patients showed evidence of radiographic residual at last follow up: 13 were simple neck residuals. Unruptured status and saccular aneurysms were associated with mRS 0/1 outcome (each p < 0.05).

Conclusions

At our hospital, MCA aneurysms are being treated with endovascular techniques, but in a minority of patients. Despite the rate of residual neck remnants, few retreatments were necessary and few rehemorrhages occurred. The periprocedural complication rate was not insignificant; therefore, in more recent years and at present, most MCA aneurysms are considered for clipping first at our center.

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Abbreviations

HH:

Hunt & Hess

ICA:

Internal carotid artery

ISAT:

International Subarachnoid Aneurysm Trial

MCA:

Middle cerebral artery

mRS:

Modified Rankin scale

SAH:

Subarachnoid hemorrhage

WFNS:

World Federation of Neurosurgical Societies

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Acknowledgements

We thank Paul H. Dressel, BFA, for assistance with preparation of the illustrations; and Debra J. Zimmer, AAS CMA-A for editorial assistance.

Sources of Funding

None in conjunction with the present work.

Conflicts of interest

Abla, Dumont, Eller, Jahshan, and Kan: nothing to disclose. Hopkins: grant/research support–St. Jude Medical, Toshiba; consultant–Abbott, Boston Scientific,* Cordis, Micrus, W.L. Gore; financial interest–AccessClosure, Augmenix, Boston Scientific,* Claret Medical Inc., Micrus, Valor Medical; board/trustee/officer position–AccessClosure, Claret Medical Inc.; speakers’ bureau–Abbott Vascular; honoraria–Bard, Boston Scientific,* Cordis, Memorial Healthcare System, Complete Conference Management, SCAI, Cleveland Clinic. Levy: research grant support (principal investigator: Stent-Assisted Recanalization in acute Ischemic Stroke, SARIS), other research support (devices), honoraria–Boston Scientific,* research support–Codman & Shurtleff, ev3/Covidien Vascular Therapies; ownership interests–Intratech Medical Ltd. and Mynx/Access Closure; consultant–Codman & Shurtleff, ev3/Covidien Vascular Therapies, TheraSyn Sensors, Inc.; fees for carotid stent training–Abbott Vascular, ev3/Covidien Vascular Therapies. He receives no consulting salary arrangements. All consulting is per project and/or per hour. Siddiqui: research grants–National Institutes of Health (co-investigator: NINDS 1R01NS064592-01A1, Hemodynamic induction of pathologic remodeling leading to intracranial aneurysms—not related to present paper), University at Buffalo; financial interests–Hotspur, Intratech Medical, StimSox, Valor Medical; consultant–Codman & Shurtleff, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra; speakers’ bureau–Codman & Shurtleff, Genentech; advisory board–Codman & Shurtleff; honoraria–Annual Peripheral Angioplasty and All That Jazz and American Association of Neurological Surgeons’ courses, Emergency Medicine Conference, Genentech, Neocure Group; also from Abbott Vascular and Codman & Shurtleff for training in carotid stenting and endovascular stenting for aneurysm. He receives no consulting salary arrangements. All consulting is per project and/or per hour. Snyder: consultant, speakers’ bureau, honoraria–Toshiba; speakers’ bureau and honoraria–ev3, The Stroke Group (consultants to the healthcare industry, Littleton CO). (*Boston Scientific’s neurovascular business has been acquired by Stryker.). Dr. Mokin has received an educational grant from Toshiba Medical Systems.

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Authors and Affiliations

  1. Department of Neurosurgery and Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, NY, USA

    Adib A. Abla, Shady Jahshan, Peter Kan, Maxim Mokin, Travis M. Dumont, Jorge L. Eller, Kenneth V. Snyder, L. Nelson Hopkins, Adnan H. Siddiqui & Elad I. Levy

  2. Department of Radiology, University at Buffalo, State University of New York, Buffalo, NY, USA

    Kenneth V. Snyder, L. Nelson Hopkins, Adnan H. Siddiqui & Elad I. Levy

  3. Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA

    Adib A. Abla, Shady Jahshan, Peter Kan, Maxim Mokin, Travis M. Dumont, Jorge L. Eller, Kenneth V. Snyder, L. Nelson Hopkins, Adnan H. Siddiqui & Elad I. Levy

  4. Jacobs Institute, Buffalo, NY, USA

    L. Nelson Hopkins

  5. University at Buffalo Neurosurgery, 100 High Street, Suite B4, Buffalo, NY, 14203, USA

    Elad I. Levy

Authors
  1. Adib A. Abla
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  2. Shady Jahshan
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  3. Peter Kan
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  4. Maxim Mokin
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  5. Travis M. Dumont
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  6. Jorge L. Eller
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  7. Kenneth V. Snyder
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  8. L. Nelson Hopkins
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  9. Adnan H. Siddiqui
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  10. Elad I. Levy
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Corresponding author

Correspondence to Elad I. Levy.

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Comment

Endovascular therapy for cerebral aneurysms has been available for more than 20 years, but attempts to treat middle cerebral artery (MCA) aneurysms successfully and with comparable results to clipping have failed thus far. Surprisingly, in many centers MCA aneurysms are increasingly treated with coils with unsatisfactory results when compared to clipping, the gold standard with several decades of experience and follow up, too. During the relatively short follow up of the published endovascular series, including the present one, problems of re-canalization and re-bleedings have proved this treatment to be inferior to clipping. Most likely with a longer follow up of the endovascular patients the difference would be even more clear. There is no need to prove this anymore unless some completely new method comes on to the market, as, for example, stents and flow diverters have not proven to be a perfect solution, either. This very experienced group of researchers, along with others, concludes that the first-line treatment of MCA aneurysms should be microsurgery, which shows that there still is a serious need for vascular neurosurgeons providing 24/7 service. Perhaps, after another 20 years most MCA aneurysms without an adjacent intracerebral hemorrhage can be considered for endovascular treatment, but we are not there yet.

Mika Niemelä

Helsinki, Finland

The institutional review board at the University at Buffalo, State University of New York, approved this study. Treatment was performed at the former Millard Fillmore Gates Circle Hospital/Kaleida Health (an affiliate of University at Buffalo) in Buffalo, New York, USA.

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Abla, A.A., Jahshan, S., Kan, P. et al. Results of endovascular treatment of middle cerebral artery aneurysms after first giving consideration to clipping. Acta Neurochir 155, 559–568 (2013). https://doi.org/10.1007/s00701-012-1594-8

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  • DOI: https://doi.org/10.1007/s00701-012-1594-8

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