Surgical Treatment of Large or Giant Fusiform Middle Cerebral Artery Aneurysms: A Case Series

BACKGROUND: Management of large or giant fusiform middle cerebral artery (MCA) aneurysms represents a significant challenge. OBJECTIVE: To describe the authors' experience in the treatment of large or giant fusiform MCA aneurysm by using various surgical techniques. METHODS: We retrospectively reviewed a database of aneurysms treated at our division between 2015 and 2017. RESULTS: Overall, 20 patients (11 males, 9 females) were identified, with a mean age of 40.7 years (range, 13-65 years; median, 43 years). Six patients (30%) had ruptured aneurysms and 14 (70%) had unruptured aneurysms. The mean aneurysm size was 19 mm (range, 10-35 mm). The aneurysms involved the prebifurcation in 5 cases, bifurcation in 4 cases, and postbifurcation in 11 cases. The aneurysms were treated by clip reconstruction (n=5), clip wrapping (n=1), proximal occlusion or trapping (n=4), and bypass revascularization (n=10). Bypasses included 7 low-flow superficial temporal arterye-MCA bypasses, 2 high-flow extracranial-intracranial bypasses, and 1 intracranial-intracranial bypass (reanastomosis). Bypass patency was 90%. Nineteen aneurysms (95%) were completely obliterated, and no rehemorrhage occurred during follow-up. There was no procedural-related mortality. Clinical outcomes were good (modified Rankin Scale score <= 2) in 18 of 20 patients (90%) at the last follow-up. CONCLUSIONS: Surgical treatment strategy for large or giant fusiform MCA aneurysms should be determined on an individual basis, based on aneurysm morphology, location, size, and clinical status. Favorable outcomes can be achieved by various surgical techniques, including clip reconstruction, wrap clipping, aneurysm trapping, aneurysm excision followed by reanastomosis, and partial trapping with bypass revascularization.