Middle Cerebral Artery Aneurysms: Pterional (Frontotemporal) Craniotomy for Clipping

We prefer surgical clipping of most ruptured and unruptured middle cerebral artery (MCA) aneurysms because of the accessibility of their location and the relatively low morbidity and durability of clipping compared with endovascular therapy. The exception is in patients in poor neurologic condition (Hunt and Hess grade IV or V).

The decision to treat an unruptured MCA aneurysm is based on an understanding of the natural history and must be weighed against the risk of surgical intervention. Factors that must be considered include the patient’s age, general health, clinical presentation (headaches, seizures), smoking history, family history of subarachnoid hemorrhage, and aneurysm size.

Generally all ruptured MCA aneurysms and unruptured MCA aneurysms greater than 7 mm should be considered for treatment

Relative contraindications include advanced age, the presence of serious medical comorbidities, and poor neurologic condition. If treatment is contemplated in patients with these relative contraindications, endovascular management may be a reasonable alternative.