Middle cerebral artery (MCA) aneurysms are common entities, and those of the bifurcation are the most frequently encountered sublocation of MCA aneurysm. MCA bifurcation (MBIF) aneurysms commonly present with subarachnoid hemorrhage (SAH), are devastating, and are often lethal. At the present time, the treatment of ruptured MBIF aneurysms entails either endovascular or open microneurosurgical methods to permanently secure the aneurysm(s). The purpose of this report is to review the current available data regarding the relative superiority of endovascular versus open microneurosurgical clipping for the treatment of ruptured middle cerebral artery bifurcation aneurysms. 1. Introduction Intracranial aneurysm rupture with resultant subarachnoid hemorrhage (aSAH) is a serious and often deadly phenomenon with an incidence that affects as many as 30,000 individuals each year in the United States [1, 2]. When cerebral aneurysms are considered by location, 40% involve the middle cerebral artery (MCA), and when all MCA aneurysms are considered by subtype, those of the MCA bifurcation (MBIF) represent 81% of all cases and 87% of all ruptured MCA aneurysms according to the Kuopio Cerebral Aneurysm Database, one of the largest population based series ever collected [3–6]. Currently, the treatment of ruptured MBIF aneurysms is immensely controversial. At present day, both endovascular coiling and microneurosurgical clipping techniques represent viable treatment modalities . However, the strengths and limitations of the two techniques suggest a complementary relationship; factors including aneurysm morphology and presence of mass effect related to hemorrhage may drive treatment selection. The history of open surgical clipping dates back to the early 1937, when American neurosurgeon Dandy clipped and secured an aneurysm of the internal carotid artery ; it was a pioneering event that many would consider the origin of modern cerebrovascular neurosurgery . Over the ensuing half century following Dandy’s report, the neurosurgical management of cerebrovascular disease continued to robustly evolve in both technique and application. Within a matter of just a few decades microneurosurgical clipping became the definite management for permanently securing cerebral aneurysms . In 1991, however, the landscape of cerebrovascular neurosurgery began to change when Guglielmi et al. reported their experience with the first detachable coils [10, 11]. Moreover, as the initial results of the International Subarachnoid Hemorrhage Trial (ISAT) emerged in 2002 demonstrating
J. B. Bederson, E. S. Connolly Jr., H. H. Batjer, et al., “Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the stroke council, american heart association,” Stroke, vol. 40, no. 3, pp. 994–1025, 2009.
M. Lehecka, R. Dashti, J. Rinne et al., “Surgical management of aneurysms of the middle cerebral artery,” in Schmidek and Sweet: Operative Neurosurgical Techniques: Indications, Methods and Results, A. Quinones-Hinojosa, Ed., pp. 897–913, Elsevier Health Sciences, 6th edition, 2012.
G. Guglielmi, F. Vinuela, I. Sepetka, and V. Macellari, “Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: electrochemical basis, technique, and experimental results,” Journal of Neurosurgery, vol. 75, no. 1, pp. 1–7, 1991.
G. Guglielmi, F. Vinuela, J. Dion, and G. Duckwiler, “Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience,” Journal of Neurosurgery, vol. 75, no. 1, pp. 8–14, 1991.
A. Molyneux, R. Kerr, I. Stratton et al., “International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial,” The Lancet, vol. 360, no. 9342, pp. 1267–1274, 2002.
J. M. C. van Dijk, R. J. M. Groen, M. T. Laan, J. R. Jeltema, J. J. A. Mooij, and J. D. M. Metzemaekers, “Surgical clipping as the preferred treatment for aneurysms of the middle cerebral artery,” Acta Neurochirurgica, vol. 153, no. 11, pp. 2111–2117, 2011.
W. Taki, N. Sakai, H. Suzuki, and PRESAT Group, “Determinants of poor outcome after aneurysmal subarachnoid hemorrhage when both clipping and coiling are available: prospective registry of subarachnoid aneurysms treatment (PRESAT) in Japan,” World Neurosurgery, vol. 76, no. 5, pp. 437–445, 2011.
T. Koivisto, R. Vanninen, H. Hurskainen, T. Saari, J. Hernesniemi, and M. Vapalahti, “Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms: a prospective randomized study,” Stroke, vol. 31, no. 10, pp. 2369–2377, 2000.
A. J. Molyneux, R. S. Kerr, L. Yu et al., “International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding , subgroups, and aneurysm occlusion,” The Lancet, vol. 366, no. 9488, pp. 809–817, 2005.
A. J. Molyneux, R. S. Kerr, J. Birks et al., “Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up,” The Lancet Neurology, vol. 8, no. 5, pp. 427–433, 2009.
S. Bracard, A. Abdel-Kerim, L. Thuillier et al., “Endovascular coil occlusion of 152 middle cerebral artery aneurysms: initial and midterm angiographic and clinical results,” Journal of Neurosurgery, vol. 112, no. 4, pp. 703–708, 2010.
A. Doerfler, I. Wanke, S. L. Goericke et al., “Endovascular treatment of middle cerebral artery aneurysms with electrolytically detachable coils,” American Journal of Neuroradiology, vol. 27, no. 3, pp. 513–520, 2006.
G. Guglielmi, F. Vi？uela, G. Duckwiler, R. Jahan, E. Cotroneo, and R. Gigli, “Endovascular treatment of middle cerebral artery aneurysms. Overall perioperative results,” Interventional Neuroradiology, vol. 14, no. 3, pp. 241–245, 2008.
N. Hirota, M. Musacchio, M. Cardoso, F. Villarejo, C. Requelme, and A. Tournade, “Angiographic and clinical results after endovascular treatment for middle cerebral artery berry aneurysms,” Neuroradiology Journal, vol. 20, no. 1, pp. 89–101, 2007.
M. Horowitz, R. Gupta, Y. Gologorsky et al., “Clinical and anatomic outcomes after endovascular coiling of middle cerebral artery aneurysms: report on 30 treated aneurysms and review of the literature,” Surgical Neurology, vol. 66, no. 2, pp. 167–171, 2006.
R. S. Quadros, S. Gallas, R. Noudel, P. Rousseaux, and L. Pierot, “Endovascular treatment of middle cerebral artery aneurysms as first option: a single center experience of 92 aneurysms,” The American Journal of Neuroradiology, vol. 28, no. 8, pp. 1567–1572, 2007.
S. Suzuki, S. Tateshima, R. Jahan et al., “Endovascular treatment of middle cerebral artery aneurysms with detachable coils: angiographic and clinical outcomes in 115 consecutive patients,” Neurosurgery, vol. 64, no. 5, pp. 876–888, 2009.
J. Vendrell, N. Menjot, V. Costalat et al., “Endovascular treatment of 174 middle cerebral artery aneurysms: clinical outcome and radiologic results at long-term follow-up,” Radiology, vol. 253, no. 1, pp. 191–198, 2009.
R. Mohammadian, M. Asgari, N. Sattarnezhad et al., “Endovascular treatment of very small and very large ruptured aneurysms of the anterior cerebral circulation: a single-center experience,” Cerebrovascular Diseases, vol. 35, no. 3, pp. 235–240, 2013.
K. H. Kim, K. C. Cha, J. S. Kim, and S. C. Hong, “Endovascular coiling of middle cerebral artery aneurysms as an alternative to surgical clipping,” Journal of Clinical Neuroscience, vol. 20, no. 4, pp. 520–522, 2013.
A. A. Abla, S. Jahshan, P. Kan et al., “Results of endovascular treatment of middle cerebral artery aneurysms after first giving consideration to clipping,” Acta Neurochirurgica, vol. 155, no. 4, pp. 559–568, 2013.
O. M. Diaz, L. Rangel-Castilla, S. Barber, R. C. Mayo, R. Klucznik, and Y. J. Zhang, “Middle cerebral artery aneurysms: a single-center series comparing endovascular and surgical treatment,” World Neurosurgery, vol. 81, no. 2, pp. 322–329, 2014.
A. Rodríguez-Hernández, M. E. Sughrue, S. Akhavan, J. Habdank-Kolaczkowski, and M. T. Lawton, “Current management of middle cerebral artery aneurysms: surgical results with a clip first policy,” Neurosurgery, vol. 72, no. 3, pp. 415–427, 2013.
E. S. Connolly, A. A. Rabinstein, J. R. Carhuapoma et al., “Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the american heart association/american stroke association,” Stroke, vol. 43, no. 6, pp. 1711–1737, 2012.
I. van der Schaaf, A. Algra, M. Wermer, et al., “Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage,” Cochrane Database of Systematic Reviews, vol. 19, no. 4, Article ID CD003085, 2005.
C. J. O'Kelly, A. V. Kulkarni, P. C. Austin, C. Wallace, and D. Urbach, “The impact of therapeutic modality on outcomes following repair of ruptured intracranial aneurysms: an administrative data analysis: clinical article,” Journal of Neurosurgery, vol. 113, no. 4, pp. 795–801, 2010.
C. Raftopoulos, P. Goffette, G. Vaz et al., “Surgical clipping may lead to better results than coil embolization: results from a series of 101 consecutive unruptured intracranial aneurysms,” Neurosurgery, vol. 52, no. 6, pp. 1280–1290, 2003.
L. Regli, A. R. Dehdashti, A. Uske, and N. De Tribolet, “Endovascular coiling compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: an update,” Acta Neurochirurgica: Supplement, vol. 82, pp. 41–46, 2002.
A. Rodríguez-Hernández, M. E. Sughrue, S. Akhavan, J. Habdank-Kolaczkowski, and M. T. Lawton, “Current management of middle cerebral artery aneurysms: Surgical results with a clip first policy,” Neurosurgery, vol. 72, no. 3, pp. 415–427, 2013.
J. Rinne, J. Hernesniemi, M. Niskanen, and M. Vapalahti, “Analysis of 561 patients with 690 middle cerebral artery aneurysms: anatomic and clinical features as correlated to management outcome,” Neurosurgery, vol. 38, no. 1, pp. 2–11, 1996.
L. Regli, A. Uske, and N. de Tribolet, “Endovascular coil placement compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: a consecutive series,” Journal of Neurosurgery, vol. 90, no. 6, pp. 1025–1030, 1999.