Endovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms: A Single-Arm Meta-Analysis and Systematic Review

doi:10.1016/j.wneu.2019.01.066

World Neurosurgery

Volume 127, July 2019, Pages 559-566

https://doi.org/10.1016/j.wneu.2019.01.066 Get rights and content

Objective

The use of endovascular treatment for ruptured middle cerebral artery (MCA) aneurysms, which have been more likely to be recommended for neurosurgical clipping because of the complex anatomic configuration, remains controversial. In the present study, the angiographic and clinical outcomes of endovascularly treated ruptured MCA aneurysms were systematically reviewed.

Methods

Online databases, including Cochrane, Medline, Web of Science, and Embase, were retrospectively and systematically searched. The primary outcomes were the immediate complete occlusion rate, mortality, complication-related mortality, and procedure-related complication rate. Meta-analysis was performed using a random or fixed effect model based on heterogeneity.

Results

A total of 14 studies with 1004 ruptured MCA aneurysms were included. The procedure-related mortality rate at discharge was 1.8% (95% confidence interval [CI], 0.9%–2.7%; I² = 0.0%; P = 0.623). The favorable clinical outcome rate at discharge was 65.4% (95% CI, 54.8%–76.0%; I² = 94.2%; P < 0.001) and had progressively increased to 73.2% (95% CI, 59.9%–86.5%; I² = 80.9%; P < 0.001). The overall complication rate was 22.7% (95% CI, 15.1%–30.3%; I² = 75.5%; P < 0.001).

Conclusion

Endovascular treatment of MCA aneurysms was related to a high incidence of procedure-related complications but a low rate of procedure-related mortality. The overall angiographic and clinical outcomes were comparable and warrant further investigation comparing clipping versus coiling for ruptured MCA aneurysms.

Introduction

Historically, neurosurgical clipping has been preferred to endovascular coiling for middle cerebral artery (MCA) aneurysms because of technological limitations. In the past decade, adjunctive balloon assistance or stent assistance have been more commonly used for these aneurysms, with comparable morbidity and mortality rates. The endovascular treatment of MCA aneurysms has been proved to be safe with comparable complication, technical failure, and repeat treatment rates.1, 2 However, for ruptured MCA aneurysms, the safety and feasibility of endovascular treatment has remained controversial.2, 3 Considering the distinctive characteristics of ruptured MCA aneurysms, the argument of whether endovascular coiling or neurosurgical clipping would be more appropriate for managing ruptured MCA aneurysms remains unclear. Therefore, we performed a meta-analysis to evaluate the safety and feasibility of endovascular management for patients with ruptured MCA aneurysms.

Section snippets

Search Strategy and Study Selection

The present systematic review and single-arm meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search and critical review of the reported data were performed to June 2018. Databases, including MEDLINE, EMBASE, the Cochrane database, and Web of Science, were searched. The title, abstract, and key words were searched using combinations of the following search terms: middle cerebral artery, intracranial or

Literature Search, Study Characteristics, and Quality Assessment

The literature search process is presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart showing the number of studies screened and excluded at each stage (Figure 1). The evidence base primarily consisted of single-arm studies. We identified 1189 studies through the database search, and a total of 14 studies1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 were included in the present meta-analysis, with 1004 ruptured MCA aneurysms.

The basic characteristics of

Discussion

Considering the particular anatomical characteristics, the preference has been to treat MCA aneurysms with surgical clipping. However, the optimal treatment of MCA aneurysms has remained controversial. In previous studies, endovascular treatment of MCA aneurysms was relatively less frequent, especially for ruptured MCA aneurysms. Thus, we analyzed the clinical and angiographic results of endovascular treatment of ruptured MCA aneurysms using a meta-analysis to investigate the safety and

Conclusion

Endovascular treatment of ruptured MCA aneurysms was related to a high incidence of procedure-related complications, with, however, a low incidence of procedure-related mortality. A more dedicated and well-controlled cohort study is warranted for further evaluation of coiling and clipping for the management of ruptured MCA aneurysms.

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Cited by (8)

Open Surgical Treatment of Middle Cerebral Artery Aneurysms: A Single-Center Series in the Endovascular Era
2024, World Neurosurgery
We review the outcomes of open surgical treatment of middle cerebral artery aneurysms (MCAAs) at a single center, focusing on aneurysm obliteration rates and functional outcomes at the most recent follow-up. These findings can be used for future comparisons of surgical outcomes with MCAAs.
We retrospectively reviewed cases from a prospectively maintained database of patients receiving open surgical treatment for ruptured or unruptured MCAAs between July 2014 and December 2022. We utilized patients' modified Rankin Scale (mRS) score and Glasgow Outcome Scale score as functional outcome measures. Means, standard deviations, medians, and interquartile ranges were calculated, and a student's t test or its nonparametric equivalent was used to compare subgroups.
One hundred fifty patients (114 women, 76%; mean age 55.0 ± 14.7 years) with a total of 156 MCAAs comprised 152 cases; 85 (56%) ruptured and 71 (46%) unruptured. Bypass was performed in 34 cases (22.4%); 18 ruptured (51.4%) and 16 unruptured (48.6%). Intraoperative rupture occurred in 5 (5%) ruptured and 1 (2%) unruptured cases. Onwe hundred forty-five patients (95.4%) had aneurysm obliteration with initial surgery, with 98.4% of patients having complete occlusion at 40.2± 65.5 weeks of follow-up. Intrahospital mortality occurred in 7 (6.9%) ruptured versus 1 (2.0%) unruptured case. Fifty-two (51.5%) of the ruptured compared to 43 (86%) unruptured patients were discharged home, with the remaining patients requiring inpatient rehabilitation or long-term hospitalization. The ruptured group had a mean hospital stay of 18.4 ± 10.5 days versus. 5.7 ± 6.0 days for unruptured. Length of stay, discharge mRS/ Glasgow Outcome Scale, and mRS at 4–6 weeks favored unruptured cases (P < 0.0001–0.0336). Mean change in mRS from presentation to last follow-up favored ruptured cases (−0.7 ± 1.2 vs. −0.04 ± 1.2, P = 0.0215).
Open surgery remains a safe and definitive treatment option for MCAAs in the endovascular era.
Procedural Complications and Factors Influencing Immediate Angiographic Results after Endovascular Treatment of Small (<5 mm) Ruptured Intracranial Aneurysms
2020, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
In the present study, immediate complete occlusion was achieved in 213 (73.4%) aneurysms, while incomplete occlusion was achieved in 77 (26.6%), including 62 (21.4%) neck remnant and 14 (4.8%) aneurysm remnants. The evaluations reported by the treating physicians in our series are very similar to those reported in other series [14-16]. The degree of initial occlusion is directly influenced by aneurysm-related anatomical factors.
Background and objective: There are technical challenges to complete occlusion of small (<5 mm) ruptured intracranial aneurysms (SRAs) using endovascular treatment (EVT). This study analyzed factors influencing immediate angiographic results in SRAs after EVT. Material and Methods: Intraoperative angiograms and medical records of 290 patients, who underwent EVT for SRAs at 2 stroke centers in China between January 2009 and October 2016, were retrospectively reviewed and evaluated. Results: Immediate complete occlusion was achieved in 213 (73.4%) aneurysms. Aneurysms with a smaller aspect ratio, those less than 3 mm in size, irregular shape, small basal outpouching, multiple aneurysms, poorer Hunt and Hess grade, and location of communication arteries demonstrated higher rates of incomplete occlusion, although the differences were not statistically significant. Multivariate logistic regression analysis revealed that SRAs with parent artery stenosis greater than or equal to 50% and lobulation demonstrated a higher incidence of incomplete occlusion. Intra-procedural rupture occurred in 13 (6.1%) patients in the complete occlusion group, and 3 (3.9%) in the incomplete occlusion group (P = .467). Thromboembolic complications occurred in 3 (1.0%) patients, and 4 (1.9%) underwent decompressive craniotomy after EVT, all of whom were in the complete occlusion group. Nine (4.2%) patients in the complete occlusion group and 2 (2.6%) in the incomplete occlusion group (P = .733) experienced intraprocedural vasospasm, with corresponding morbidity and mortality rates of 15.0% and 2.1%, respectively. Conclusions: Proximal parent artery stenosis greater than or equal to 50% and lobulation were independent predictors of incomplete occlusion in patients with SRAs. Higher rates of intraprocedural rupture, thromboembolic complications, intraprocedural vasospasm, and mortality were found in the complete occlusion group; however, these differences were not statistically significant. Complete occlusion of SRAs may be achieved without additional mortality and perioperative complications.
Changes in treatment of intracranial aneurysms during the last decade in a large European neurovascular center
2024, Acta Neurochirurgica
A shift from open to endovascular repair in the treatment of ruptured middle cerebral artery aneurysms: a single institution experience
2023, Neuroradiology
Endovascular treatment of middle cerebral artery aneurysms: current status and future prospects
2023, Frontiers in Neurology
Simple endovascular coiling: An effective long-term solution for wide-necked ruptured middle cerebral artery aneurysms? A 10-years retrospective study
2022, Neuroradiology Journal

View all citing articles on Scopus

: Conflict of interest statement: The present study was supported by the National Key R&D Program of China (grant 2016YFC1300700) and the National Natural Science Foundation of China (grant 81701136).

: Xiaoxi Zhang, Yu Zhou and Qiao Zuo contributed equally to the present study.

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Literature ReviewEndovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms: A Single-Arm Meta-Analysis and Systematic Review

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Search Strategy and Study Selection

Literature Search, Study Characteristics, and Quality Assessment

Discussion

Conclusion

Surg Neurol

Lancet

World Neurosurg

Neurochirurgie

Endovascular treatment of 300 consecutive middle cerebral artery aneurysms: clinical and radiologic outcomes

AJNR Am J Neuroradiol

Endovascular treatment of 346 middle cerebral artery aneurysms: results of a 16-year single-center experience

Neurosurgery

Endovascular treatment of middle cerebral artery aneurysms: a systematic review and single-center series

Neurosurgery

Treatment of ruptured middle cerebral artery aneurysms by endovascular approach: a single-center experience

Int J Neurosci

Analysis of endovascular treatment of ruptured aneurysms of the middle cerebral artery compared to other anatomical locations

Interv Neuroradiol

Simple coiling using single or multiple catheters without balloons or stents in middle cerebral artery bifurcation aneurysms

Neuroradiology

Treatment results for complex middle cerebral artery aneurysms: a prospective single-center series

Acta Neurochir

Literature Review
Endovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms: A Single-Arm Meta-Analysis and Systematic Review