Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies

Because of the diversity of aneurysm morphology, complicated arterial anatomy and hemodynamic characteristics, tailored surgical treatments are required for cases of individual complex middle cerebral artery (MCA) aneurysms.

During an 8-year period, 59 complex MCA aneurysms in 58 patients were treated microsurgically in our department. Complex aneurysms were defined as having large (10-24 mm in diameter) or giant (diameter ≥ 25 mm) size or non-saccular morphology (fusiform, dissecting or serpentine).

Direct clipping of the aneurysmal necks was achieved in eight patients, while reconstructive clipping was performed in 25 patients. Indirect aneurysm occlusion was performed in 25 cases, including trapping or resecting the aneurysm in four cases, trapping or resecting the aneurysm with extra-intracranial (EC) or intra-intracranial (IC) bypass in 21 cases and internal carotid artery (ICA) sacrifice with EC-IC bypass in one case. Forty-eight aneurysms (81.4%) were completely obliterated. Graft patency was confirmed in 20 of 21 cases (95.2%) with bypass. A recurrent aneurysm was detected in one case and a re-operation was performed. Two patients with Hunt-Hess grade IV aneurysms died during the perioperative period. Overall, 52 cases (88.1%) had good outcomes (Glasgow Outcome Scale ≥ 4) during the late follow-up period.

The surgical modality and strategy for treating complex MCA aneurysm are decided according to the morphology of the aneurysm, vascular anatomy and the hemodynamic characteristics of each case. Thus, we developed a new classification based on the angioarchitecture. Favorable outcomes can be achieved by treating complex MCA aneurysms with appropriate surgical modalities, strategies and techniques.