Aggressive Behavior of Recurrent Middle Cerebral Artery Aneurysms: A Case Series

The bifurcation of the middle cerebral artery (MCA) is one of the most common sites for the formation of cerebral aneurysms, presenting significant challenges for surgical management. A primary concern in this area is the recurrence of aneurysms following surgical clipping, which necessitates a thorough investigation of the contributing factors. This study examined all cases of rebleeding from previously clipped MCA aneurysms among 195 surgically treated patients over an 11-year period. Our evaluation utilized detailed clinical records, imaging studies, and surgical video documentation. We specifically analyzed the direction of the aneurysmal dome, the type of clip used, clipping angles, and various factors that may contribute to rebleeding. Out of the 195 cases, three patients (1.5%) experienced rebleeding within four to 12 months following the initial clipping. Among these three cases, one was evaluated using digital subtraction angiography (DSA) post-clipping, while the other two were assessed with computed tomography angiography (CTA). The recurrence cases were characterized by atypical and aggressive patterns, involving rapid morphological changes that necessitated additional interventions. Surgical management for these cases included re-clipping or aneurysmectomy combined with revascularization procedures to address the recurring aneurysms. The findings of this study highlight the importance of understanding the relationship between anatomical and technical factors in the surgical management of MCA aneurysms. By identifying patterns associated with recurrence, this research seeks to improve decision-making processes and optimize strategies for managing recurrent aneurysms after clipping. Differences in imaging techniques may have affected the sensitivity in detecting small residual necks. This comprehensive approach can potentially enhance long-term outcomes for patients receiving treatment for MCA aneurysms.