Microsurgical management of complex middle cerebral artery aneurysms

Literature review and a series of cases


  • Andrey Dubovoy Federal Neurosurgical Center, Novosibirsk, Russia
  • Evgeniy Lekchnov Federal Neurosurgical Center, Novosibirsk, Russia
  • Dmitriy Galaktionov Federal Neurosurgical Center, Novosibirsk, Russia
  • Konstantin Ovsyannikov Federal Neurosurgical Center, Novosibirsk, Russia
  • Anatoliy Bervitskiy Federal Neurosurgical Center, Novosibirsk, Russia
  • Aleksey Sosnov Federal Neurosurgical Center, Novosibirsk, Russia
  • Jamil Rzaev Federal Neurosurgical Center, Novosibirsk, Russia




giant aneurysm, complex aneurysm, middle cerebral artery, bypass surgery



Management of complex aneurysms of the middle cerebral artery (MCA) is very challenging and require individualized treatment strategies. The aim of our review was to analyze experience with the treatment of complex MCA aneurysms using revascularization and artery sacrifice techniques.


We have reviewed 9 original articles on patients' treatment with complex MCA aneurysms. Depending on localization of complex aneurysm of MCA various methods of parent artery sacrifice, revascularization strategies, surgical results, outcomes and complications were reviewed.


We have analyzed treatment of 244 patients with 246 complex MCA aneurysms in 9 different groups. From 67 to 100% of cases the aneurysms were occluded successfully. Bypass patency being a result of the performed revascularization methods was from 83.3 to 100%. The main complications included ischemic disorders related to occlusion of the bypass graft or perforators injury. Morbidity in some reviews varied from 2.4 to 6.9%. The majority of patients in late follow-up showed good outcomes 0-2 on modified Rankin scale and 4-5 on Glasgow Outcome Scale. Illustrative clinical cases of the patients with complex MCA aneurysms treated at the Federal Neurosurgical Center were presented.


Complex aneurysms of the MCA are very challenging lesions. The surgical strategy for treating complex MCA aneurysm should take into account vascular anatomy, complex aneurysm morphology, its localization and rupture status of each case


Esposito G, Fierstra J, Regli L. Distal outflow occlusion with bypass revascularization: last resort measure in managing complex MCA and PICA aneurysms. Acta Neurochir. 2016 Aug;158(8):1523–31. doi:10.1007/s00701-016-2868-3

Tayebi Meybodi A, Huang W, Benet A, Kola O, Lawton MT. Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization. Journal of Neurosurgery. 2017 Sep;127(3):463–79. doi:10.3171/2016.7.JNS16772

Wang L, Lu S, Cai L, Qian H, Tanikawa R, Shi X. Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms. Neurosurgical Focus. 2019 Feb;46(2):E10. doi:10.3171/2018.11.FOCUS18457

Zhu W, Liu P, Tian Y, Gu Y, Xu B, Chen L, et al. Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies. Acta Neurochir. 2013 Aug;155(8):1481–91. doi:10.1007/s00701-013-1751-8

Dengler J, Heuschmann PU, Endres M, Meyer B, Rohde V, Rufenacht DA, et al. The Rationale and Design of the Giant Intracranial Aneurysm Registry: A Retrospective and Prospective Study. International Journal of Stroke. 2011 Jun;6(3):266–70. doi: 10.1111/j.1747-4949.2011.00588.x

Kalani MYS, Zabramski JM, Hu YC, Spetzler RF. Extracranial-Intracranial Bypass and Vessel Occlusion for the Treatment of Unclippable Giant Middle Cerebral Artery Aneurysms. Neurosurgery. 2013 Mar 1;72(3):428–36. doi:10.1227/NEU.0b013e3182804381

Kivipelto L, Niemelä M, Meling T, Lehecka M, Lehto H, Hernesniemi J. Bypass surgery for complex middle cerebral artery aneurysms: impact of the exact location in the MCA tree: Clinical article. JNS. 2014 Feb;120(2):398–408. doi:10.3171/2013.10.JNS13738

Wessels L, Fekonja LS, Vajkoczy P. Bypass surgery of complex middle cerebral artery aneurysms—technical aspects and outcomes. Acta Neurochir. 2019 Oct;161(10):1981–91. doi:10.1007/s00701-019-04042-9

Cenzato M, Bortolotti C. The role of extra- and intracranial bypass in the treatment of complex aneurysms. J Neurosurg Sci. 2016 Mar;60(1):70–82.

Natarajan SK, Zeeshan Q, Ghodke BV, Sekhar LN. Brain Bypass Surgery for Complex Middle Cerebral Artery Aneurysms: Evolving Techniques, Results, and Lessons Learned. World Neurosurgery. 2019 Oct;130:e272–93. doi:10.1016/j.wneu.2019.06.059

Kato N, Prinz V, Finger T, Schomacher M, Onken J, Dengler J, et al. Multiple reimplantation technique for treatment of complex giant aneurysms of the middle cerebral artery: technical note. Acta Neurochir. 2013 Feb;155(2):261–9. doi:10.1007/s00701-012-1538-3

Link TW, Boddu SR, Hammad HT, Knopman J, Lin N, Gobin P, et al. Endovascular treatment of middle cerebral artery aneurysms: A single center experience with a focus on thromboembolic complications. Interv Neuroradiol. 2018 Feb;24(1):14–21. doi: 10.1177/1591019917738961

Zhu F, Chui J, Herrick I, Martin J. Intraoperative evoked potential monitoring for detecting cerebral injury during adult aneurysm clipping surgery: a systematic review and meta-analysis of diagnostic test accuracy. BMJ Open. 2019 Feb;9(2):e022810. doi: 10.1136/bmjopen-2018-022810

Scerrati A, Sabatino G, Della Pepa GM, Albanese A, Marchese E, Puca A, et al. Treatment and outcome of thrombosed aneurysms of the middle cerebral artery: institutional experience and a systematic review. Neurosurg Rev. 2019 Sep;42(3):649–61. doi:10.1007/s10143-018-0984-7

Ravina K, Rennert RC, Kim PE, Strickland BA, Chun A, Russin JJ. Orphaned Middle Cerebral Artery Side-to-Side In Situ Bypass as a Favorable Alternative Approach for Complex Middle Cerebral Artery Aneurysm Treatment: A Case Series. World Neurosurgery. 2019 Oct;130:e971–87. doi:10.1016/j.wneu.2019.07.053

Lee C-H, Tsai S-T, Chiu T-L. Superficial temporal artery-middle cerebral artery bypass for the treatment of complex middle cerebral artery aneurysms. Tzu Chi Med J. 2018;30(2):110. doi:10.4103/tcmj.tcmj_193_17

Amin-Hanjani S, Alaraj A, Charbel FT. Flow replacement bypass for aneurysms: decision-making using intraoperative blood flow measurements. Acta Neurochir. 2010 Jun;152(6):1021–32. doi:10.1007/s00701-010-0635-4

da Silva HB, Messina-Lopez M, Sekhar LN. Bypasses and Reconstruction for Complex Brain Aneurysms. Methodist DeBakey Cardiovascular Journal. 2014 Oct;10(4):224–33. doi:10.14797/mdcj-10-4-224

Wang L, Cai L, Lu S, Qian H, Lawton MT, Shi X. The History and Evolution of Internal Maxillary Artery Bypass. World Neurosurgery. 2018 May;113:320–32. doi: 10.1016/j.wneu.2018.02.158

Sekhar LN, Tariq F, Mai JC, Kim LJ, Ghodke B, Hallam DK, et al. Unyielding Progress: Treatment Paradigms for Giant Aneurysms. Neurosurgery. 2012 Oct;59:6–21. doi:10.1227/NEU.0b013e3182698b75

Wessels L, Fekonja LS, Achberger J, Dengler J, Czabanka M, Hecht N, et al. Diagnostic reliability of the Berlin classification for complex MCA aneurysms—usability in a series of only giant aneurysms. Acta Neurochir. 2020 Nov;162(11):2753–8. doi: 10.1007/s00701-020-04565-6

Aboukais R, Verbraeken B, Leclerc X, Gautier C, Vermandel M, Bricout N, et al. Protective STA-MCA bypass to prevent brain ischemia during high-flow bypass surgery: case series of 10 patients. Acta Neurochir. 2019 Jun;161(6):1207–14. doi:10.1007/s00701-019-03906-4

Jean WC, Felbaum DR, Ngo HM. How I do it: superficial temporal artery to middle cerebral artery bypass for treatment of giant middle cerebral artery aneurysm. Acta Neurochir. 2020 Mar;162(3):593–6. doi:10.1007/s00701-019-04202-x

Ansari A, Kalyan S, Sae-Ngow T, Yamada Y, Tanaka R, Kawase T, et al. Review of avoidance of complications in cerebral aneurysm surgery: The Fujita experience. Asian J Neurosurg. 2019;14(3):686. doi:10.4103/ajns.AJNS_131_17

Sia SF, Morgan MK. High flow extracranial-to-intracranial brain bypass surgery. Journal of Clinical Neuroscience. 2013 Jan;20(1):1–5. doi:10.1016/j.jocn.2012.05.007

Walcott BP, Reinshagen C, Stapleton CJ, Choudhri O, Rayz V, Saloner D, et al. Predictive modeling and in vivo assessment of cerebral blood flow in the management of complex cerebral aneurysms. J Cereb Blood Flow Metab. 2016 Jun;36(6):998–1003. doi:10.1177/0271678X16641125

Xin W, Xin Q, Yang X. Meta-Analysis of Clipping versus Coiling for the Treatment of Unruptured Middle Cerebral Artery Aneurysms: Direct Comparison of Procedure-Related Complications. NDT. 2019 Dec;Volume 15:3387–95. doi: 10.2147/NDT.S226353

Vannemreddy P, Nourbakhsh A, Nanda A. Evaluation of the Prognostic Indicators of Giant Intracranial Aneurysms. Skull Base. 2011 Jan;21(01):037–46. doi: 10.1055/s-0030-1263285

Fernandes S, Alves R, Dória-Netto H, Puglia Júnior P, Rivau F, Jory M. Treatment of complex intracranial aneurysm: Case report of the simultaneous use of endovascular and microsurgical techniques. Surg Neurol Int. 2016;7(42):1060. doi: 10.4103/2152-7806.196375

Skrap M, Petralia B, Toniato G. The combined treatment of stenting and surgery in a giant unruptured aneurysm of the middle cerebral artery. Surg Neurol Int. 2015;6(1):67. doi: 10.4103/2152-7806.155802

Cover Image




How to Cite

Dubovoy, A. ., Lekchnov, E., Galaktionov , D. ., Ovsyannikov , K. ., Bervitskiy , A. ., Sosnov , A. . ., & Rzaev , J. . (2021). Microsurgical management of complex middle cerebral artery aneurysms: Literature review and a series of cases. Neurohirurgija - The Serbian Journal of Neurosurgery, 1(1). https://doi.org/10.55005/sjns.v1i1.2