Microneurosurgical management of proximal middle cerebral artery aneurysms

Background: The M1As are located in the main trunk (M1) of the MCA, between the bifurcation of the ICA and the main bifurcation of M1. Proximal MCA aneurysms are often small and thin-walled, which makes their proper clipping tedious. There are few reports on their microsurgery. Methods: This review, and the whole series on intracranial aneurysms, is mainly based on the personal microneurosurgical experience of the senior author (JH) in 2 Finnish centers (Helsinki and Kuopio), which serve, without selection, the catchment area in the southern and eastern Finland. Results: These 2 centers have treated more than 10 000 patients with aneurysm since 1953. We review the practical anatomy, preoperative planning, and avoidance of complications in the microsurgical dissection and clipping of M1As which form 7.4% of all intracranial and 14% of all MCA aneurysms in our patients. Conclusions: Proximal MCA aneurysms are often wide-necked and intimately connected to an M1 branch at its origin on M1, features that favor exosurgery rather than endosurgery. The direction and course of the parent and branching arteries and the orientation of the fundus are the most important factors affecting the efficacy and safety of clipping.