Surgical management of complex middle cerebral artery aneurysms

Complex middle cerebral artery (MCA) aneurysms are defined in this review as aneurysms larger than 20 mm, arising from the MCA bifurcation, and requiring unusual surgical approaches for their obliteration. The direct surgical approaches to complex MCA aneurysms can be divided into five techniques: 1) direct clipping, 2) trapping, 3) trapping and extracranial-intracranial anastomosis, 4) excision and end-to-end anastomosis, and 5) external wrapping. The pertinent surgical anatomy, preoperative preparation, intraoperative procedures, operative approaches, and potential complications will be reviewed.