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Endovascular and Surgical Options for Ruptured Middle Cerebral Artery Aneurysms: Review of the Literature

DOI: 10.1155/2014/315906

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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 [7]. 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 [8]; it was a pioneering event that many would consider the origin of modern cerebrovascular neurosurgery [9]. 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 [6]. 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

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