Introduction: Microsurgical clipping results with MCA aneurysms have been reported as being excellent, thereby raising debate about the optimal first-line therapy for these patients. We aimed to establish the efficacy of endovascular treatment (EVT) as first-line therapy for ruptured MCA saccular aneurysms.

Methods: Patients with confirmed aneurysmal SAH attributed to MCA aneurysms and treated with EVT or conventional microsurgical clipping between May 2000 to April 2012 were included. The data collated included immediate angiographic occlusion; clinical outcome at 3 months; anatomical outcome on digital subtraction angiography (pre-2004) and magnetic resonance angiography (post-2004) at 6 and 30 months follow-up.

Results: 217 patients underwent EVT, whilst 61 underwent surgical clipping with a mean age of 53 versus 55 years respectively. WFNS grade 1 patients comprised 57% and 49% of the EVT and surgical groups respectively with 15% of the EVT and 26% of the surgical group being Grade 2. Complete or near complete endovascular occlusion was achieved in 95% of cases. Of 163 aneurysms with angiographic follow-up, only 10 needed retreatment. Endovascular procedural morbidity and mortality rate was 9%. 79% versus 77% of patients in the EVT and surgical groups respectively demonstrated a GOS score of 4 or 5. 64% versus 47% achieved GOS 5 in EVT and surgical groups respectively. Mortality rate in the surgical group was 9.8%.

Conclusions: Favourable clinical outcome was achieved in majority of MCA ruptured aneurysms with EVT with high occlusion rates and low morbidity and mortality. EVT is a sensible first-line treatment for this group. This study supports that EVT for MCA aneurysms provides comparable or better outcomes than previously reported.

Patient Care: By presenting our extensive experience, we will add to the current reported literature on this subject, and allow clinicians to debate and consider the first-line treatment options for ruptured MCA aneurysms.

Learning Objectives: Partcipants: 1)should be able to consider and debate first-line treatment options for ruptured MCA aneurysms in light of the current reported literature and our experience in treatment of these aneurysms with EVT and microsurgical clipping; 2) will become familiar with the current reported literature with respect to first-line treatment options and its selection for ruptured MCA aneurysms.

References: 1) Rodríguez-Hernández A, Sughrue ME, Akhavan S, Habdank-Kolaczkowski J, Lawton MT. Current management of middle cerebral artery aneurysms: surgical results with a "clip first" policy. Neurosurgery 2013;7(3):415-27. 2) Molyneux AJ, Kerr RS, Yu LM, et al. International subarachnoid aneurysm trial(ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival,dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005;366(9488):809-817. 3)McDougall CG, Spetzler RF, Zabramski JM, et al. The Barrow Ruptured Aneurysm Trial. J Neurosurg. 2012;116(1):135-144. 4) Iijima A, Piotin M, Mounayer C, Spelle L, Weill A, Moret J. Endovascular treatment with coils of 149 middle cerebral artery berry aneurysms. Radiology. 2005;237(2):611-619.