Clipping versus coiling for treatment of middle cerebral artery aneurysms: a retrospective Italian multicenter experience

Abstract

Endovascular treatment has emerged as the predominant approach in intracranial aneurysms. However, surgical clipping is still considered the best treatment for middle cerebral artery (MCA) aneurysms in referral centers. Here we compared short- and long-term clinical and neuroradiological outcomes in patients with MCA aneurysms undergoing clipping or coiling in 5 Italian referral centers for cerebrovascular surgery. We retrospectively reviewed 411 consecutive patients admitted between 2015 and 2019 for ruptured and unruptured MCA aneurysm. Univariate and multivariate analyses of the association between demographic, clinical, and radiological parameters and ruptured status, type of surgical treatment, and clinical outcome at discharge and follow-up were performed. Clipping was performed in 340 (83%) cases, coiling in 71 (17%). Clipping was preferred in unruptured aneurysms and in those showing collateral branches originating from neck/dome. Surgery achieved a higher rate of complete occlusion at discharge and follow-up. Clipping and coiling showed no difference in clinical outcome in both ruptured and unruptured cases. In ruptured aneurysms age, presenting clinical status, intracerebral hematoma at onset, and treatment-related complications were significantly associated with outcome at both short- and long-term follow-up. The presence of collaterals/perforators originating from dome/neck of the aneurysms also worsened the short-term clinical outcome. In unruptured cases, only treatment-related complications such as ischemia and hydrocephalus were associated with poor outcome. Clipping still seems superior to coiling in providing better short- and long-term occlusion rates in MCA aneurysms, and at the same time, it appears as safe as coiling in terms of clinical outcome.

Changes in treatment of intracranial aneurysms during the last decade in a large European neurovascular center

“…Consequently, treatment-associated risks are higher and aneurysm occlusion rates are often lower than for other aneurysm locations treated endovascularly [ 24 , 46 ] or compared to microsurgical clipping [ 35 ]. Still, there are studies showing good angiographic results and relatively low risks of complications following endovascular treatment for specific MCA aneurysms [ 4 , 5 , 13 , 28 , 31 , 41 , 51 ]. Given the current patient volumes of surgically treated aneurysm patients, even in high-volume neurovascular centers, and the challenges it poses to the training of future neurovascular surgeons, as well as the swift development of endovascular devices, it seems likely that a similar shift for MCA aneurysms will take place.…”

Comparison Between Intrasylvian and Intracerebral Hematoma Associated with Ruptured Middle Cerebral Artery Aneurysms: Clinical Implications, Technical Considerations, and Outcome Evaluation

“…Although an early open surgery still represents the treatment of choice in many neurosurgical units in almost all cases of MCA aneurysms especially when associated with larger ICH or ISH [17], different treatment paradigms are prevalent in other centers where the vascular neurosurgery expertise has progressively declining and the endovascular obliteration emerges as the rst approach in all ruptured aneurysms [14][15][16], including those associated with hematomas whose evacuation is therefore delayed after having secured the aneurysm. Nevertheless, a combined endovascular obliteration rst and hematoma evacuation after has been advocated also by teams having strong expertise in vascular neurosurgery as reasonable option in selected patients with SAH and associated ICH as this treatment paradigm can transform a complex surgery in an easier and quicker decompression [19].…”

“…Probably, in the future, a new generation of cerebrovascular surgeons with double vascular/endovascular expertise and dedicated hybrid operating rooms may contribute to shorten the time between the two procedures and make this mixed option preferable in some patients. However, preserving an expertise in open neurovascular surgery is still mandatory, as a high percentage of MCA aneurysms are irregular in morphology and a full embolization often requires a stent assistance and double antiplatelet therapy even in acute conditions after bleeding [17]. Thus, an attitude towards a hybrid procedure not only may delay the evacuation of the blood clot, but also increases the risk of a new hemorrhagic infarction after the second surgery due to antiplatelets therapy during the endovascular procedure.…”

Unruptured intracranial aneurysms: Why should we focus on small aneurysms? A comprehensive update of recent findings

“…Surgical clipping requires less strict ambulatory control and, in most cases, does not require invasive follow-up imaging, apart from MRA or CTA. As for MCA aneurysms, the outcomes remain indifferent between endovascular and surgical groups, while clipping provided better occlusion rates [ 73 ]. ACoA IAs are yet another group often qualifiable for both approaches.…”