title: Current management of middle cerebral artery aneurysms:  surgical results with a "clip first" policy.
abstract: BACKGROUND
  One response to randomized trials like the International Subarachnoid Aneurysm Trial has been to adopt a "coil first" policy, whereby all aneurysms be considered for coiling, reserving surgery for unfavorable aneurysms or failed attempts. Surgical results with middle cerebral artery (MCA) aneurysms have been excellent, raising debate about the respective roles of surgical and endovascular therapy.
  
  
  OBJECTIVE
  To review our experience with MCA aneurysms managed with microsurgery as the treatment of first choice.
  
  
  METHODS
  Five hundred forty-three patients with 631 MCA aneurysms were managed with a "clip first" policy, with 115 patients (21.2%) referred from the Neurointerventional Radiology service and none referred from the Neurosurgical service for endovascular management.
  
  
  RESULTS
  Two hundred eighty-two patients (51.9%) had ruptured aneurysms and 261 (48.1%) had unruptured aneurysms. MCA aneurysms were treated with clipping (88.6%), thrombectomy/clip reconstruction (6.2%), and bypass/aneurysm occlusion (3.3%). Complete aneurysm obliteration was achieved with 620 MCA aneurysms (98.3%); 89.7% of patients were improved or unchanged after therapy, with a mortality rate of 5.3% and a permanent morbidity rate of 4.6%. Good outcomes were observed in 92.0% of patients with unruptured and 70.2% with ruptured aneurysms. Worse outcomes were associated with rupture (P = .04), poor grade (P = .001), giant size (P = .03), and hemicraniectomy (P < .001).
  
  
  CONCLUSIONS
  At present, surgery should remain the treatment of choice for MCA aneurysms. Surgical morbidity was low, and poor outcomes were due to an inclusive policy that aggressively managed poor-grade patients and complex aneurysms. This experience sets a benchmark that endovascular results should match before considering endovascular therapy an alternative for MCA aneurysms.
authors.affiliation: Department of Neurological Surgery, University of California at San Francisco, San Francisco, California 94143, USA.
authors.forename: Ana
authors.initials: A
authors.lastname: Rodríguez-Hernández
authors.forename: Michael E
authors.initials: ME
authors.lastname: Sughrue
authors.forename: Sina
authors.initials: S
authors.lastname: Akhavan
authors.forename: Julian
authors.initials: J
authors.lastname: Habdank-Kolaczkowski
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D017542:Aneurysm, Ruptured / Q000601:surgery; D015901:Angiography, Digital Subtraction; D003399:Craniotomy; D057510:Endovascular Procedures / Q000592:standards*; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000473:pathology / Q000601:surgery; D002532:Intracranial Aneurysm / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D007431:Intraoperative Complications / Q000601:surgery; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000473:pathology / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000592:standards*; D016896:Treatment Outcome