Navigating Complexity: A Comprehensive Approach to Middle Cerebral Artery Aneurysms.

Area of Science:

• Neurosurgery
• Vascular Neurology
• Interventional Neuroradiology

Background:

• The definition of aneurysm complexity is evolving with endovascular treatment advancements.
• Surgical clipping remains a key treatment for middle cerebral artery (MCA) aneurysms.
• Classical criteria for surgically complex MCA aneurysms need updating.

Purpose of the Study:

• To review institutional experience with complex MCA aneurysms.
• To analyze factors influencing treatment decisions for complex MCA aneurysms.
• To propose a treatment strategy algorithm for complex MCA aneurysms.

Main Methods:

• Retrospective review of institutional cases involving complex MCA aneurysms.
• Analysis of individual aneurysmal factors impacting treatment choices.
• Evaluation of complexity criteria such as shape, size, neck width, and vessel involvement.

Main Results:

• 14 complex MCA aneurysms were identified, each with multiple complexity criteria.
• Common features included fusiform shape (57%), large/giant size (35%/21%), sac-originating vessels (50%), intrasaccular thrombi (35%), and wide necks (92%).
• Proximal vessel tortuosity or stenosis affected 28% of cases.

Conclusions:

• Optimal management of complex MCA aneurysms necessitates a decision-making algorithm.
• The algorithm should incorporate aneurysm morphology and patient characteristics.
• Tailored treatment strategies may involve combined endovascular and surgical techniques.