Characteristics of middle cerebral artery aneurysms treated endovascularly in a clip-favored institution

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Background The emergence of flow disruptors has brought a dynamic transition in the selection of treatment for middle cerebral artery (MCA) aneurysms, and the number of MCA aneurysms clipped is acceleratingly decreasing. Still, retreatment after endovascular treatment is still a dilemma, which may necessitate surgical clipping. It is all the more important to elucidate characteristics of MCA aneurysms that make clipping unfavorable. Thus, the practical characteristics of MCA aneurysms treated endovascularly in a clip-favored institution before the usage of flow disruption devices were investigated. Methods This is a retrospective, single-center observational study. The clinical and imaging characteristics of treated MCA aneurysms from January 2012 to May 2022 were analyzed. Results A total of 83 aneurysms were included; 70 aneurysms (84%) were clipped, and 13 (16%) were treated endovascularly. Eighteen aneurysms (22%) were ruptured (clipping, 12; endovascular, 6). The reasons for an endovascular treatment were as follows: distal (3); subacutely ruptured with burdens of spasm (2); multiple aneurysms (6: another clipped in 3, coiled in 1, and conservatively managed in 2); no access to the operating room due to COVID-19 (1); and retreatment after coiling (1). Endovascular group aneurysms were smaller (maximum diameter 5.2 vs 7.3 mm, p < 0.01, as well as dome, neck, and height) without differences in the dome/neck and aspect (height/neck) ratios. In a subgroup analysis of 78 MCA bifurcation aneurysms, the endovascular group was still smaller (dome 4.4 vs 5.8 mm, p = 0.025; neck 2.8 vs 3.9, p = 0.03). Conclusion In a limited series from a clip-favored institution before the flow disruption era, factors guided to endovascular treatments on MCA aneurysms were rather anatomical and clinical factors such as distal location, subacutely ruptured, multiple, or retreatment after coiling, than morphological factors such as dome/neck and aspect ratios albeit smaller size.

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