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Objective: Rupture of an MCA aneurysm yields the worst results of all aneurysm locations. A specific minimally invasive approach has been designed. The results of aneurysm clipping using this approach are evaluated and compared with MCA aneurysm endovascular treatment in the same time period—2000–2008. The results were compared with historical controls. In 1990–1999, when only surgery was available, our results were: total mortality and morbidity (MM) 22.7%(n = 119), 0% in Hunt and Hess (HH) grade 0 patients (n = 25), 9% in HH 1–3 patients (n = 55), and 56% in HH 4–5 patients (n = 39).
Methods: Ruptured aneurysms are treated as soon as possible with no respect to the patient's condition and timing. Unruptured aneurysms are treated individually but actively. A total of 171 patients with M 1–2 aneurysms were treated in the last 9 years. Of these, 109 were clipped and 62 coiled. Surgery was performed through a linear 6-cm long incision, with a single burr hole above the pterion and a craniotomy 35–40 mm in diameter above the sylvian fissure. The arachnoid of the sylvian fissure was opened in a length of 25–30 mm, and the aneurysm was dissected and clipped in a retrograde fashion. The Fisher exact test was used for statistical evaluation of results.
Results: The MM rate in clipped aneurysms was 27% compared with 37%(P = 0.17) in coiled patients. Bad results were almost invariably caused by initial intracerebral bleeding, where the best result was severe and permanent hemiparesis (GOS 3 at best). In clipped unruptured aneurysms, MM was 0%(n = 35); in coiled aneurysms it was 5.3%(n = 22; P = 0.14). In HH 1–3 clipped aneurysms, MM was 13%(n = 46), and in coiled aneurysms it was 37.5%(n = 24; P = 0.03). In HH 4–5 clipped aneurysms, MM was 82.1%(n = 28); in coiled aneurysms it was 75%(n = 16; P = 0.70). Intracranial hematoma (ICH) was present in 24% of clipped and 21% of coiled HH 1–3 patients, and in 86% of clipped and 44% of coiled HH 4–5 patients (P = 0.09). Aneurysm regrowth requiring a second coiling session was necessary in 1 patient only. Statistically, the results were not different from our historical series.
Conclusion: Minimally invasive surgery of M 1–2 aneurysms is superior to coiling in patients, with fast, safe, and permanent securing of their aneurysms. In case of a ruptured aneurysm of a patient in “good” clinical condition, the superiority of clipping over coiling reached statistical significance. Actually, endovascular procedures worsened our overall results. Recently, coiling of MCA aneurysms is reserved for older patients in a poor neurological and medical condition.