1. O Mansour, J Weber and M Schumacher Neuroradiology Depart. Freiburg Univ. Neurology Depart. Alexandria Univ. Department of Neuroradiology, Neurocenter University of Freiburg, Germany Alexandria University, Faculty of medicine Neurology Depart. Egypt

2.  Endovascular coiling of MCA aneurysms has shown higher procedural failure rate and less favorable results compared to the treatment of aneurysms at other sites (ISAT group, Lancet 2002; Suzuki S,Neurosurgery 2009)  In ruptured MCA aneurysms, subgroup analysis of ISAT in older patients more than 65 years revealed inferiority of coiling to clipping (Ryttlefors M, Stroke 2008)

3. Elderly patients with ruptured MCA aneurysms benefit more from neurosurgical clipping. M Ryttlefors et al, Stroke 2008

4. Another hindering factor is what is called the wild morphological gallery of MCA aneurysm ICH more often associated with ruptured MCA aneurysms Reasons for less favorable outcome :

5. Pretreatment study of morphology in 126 MCA aneurysms

6. Russian Matroska appearance

7. Marge simpson head

8. Dew drop

9. In the treatment of unruptured intracranial aneurysms endovascular coiling has shown equal or superior results to clipping (Higashida RT, AJNR 2007) unruptured But for unruptured MCA aneurysms coiling has been limited, mainly due to the unfavorable aneurysm geometry (wide neck and/or incorporation of a branch into the neck) (Doerfler A, AJNR 2006)

10. Modified endovascular techniques and devices, such as multi-catheter, balloon-assisted, stent-assisted, or combination of these, permit coiling even of aneurysms having a complex anatomy (Lubicz B, AJNR 2006)

11. Methods and patients  Patients with mild neurological deficit (mRS, 0 - 2) were included  Former SAH from another aneurysm  Who accidentally discovered during non hemorrhagic neurological manifestation  Between 2001-2009 retrospectively 70 patients with 76 unruptured MCA aneurysms were included, reviewed and evaluated.  30 men and 40 women aged from 27 to 77 years (mean, 59 years)

13. Mean age of our cohort was 59 years with IQR ( 27-77 years), 30 (42.9%) patients were male.

14. Results Table 1: aneurysms measurements and endovascular methods used in occlusion. SINGLE CATHETER (n=30,40%) Multicatheter (n=18, 24%) Balloon-assisted (n =11, 14.7%) Stent-assisted (n=13,17.3%) Multi-catheter+ballon (n=3,4%) Mean of Aneurysm Sac Size 7.5mm (range, 3 – 19mm) Aneurysm neckWide neck (n=41, 53.9%) Narrow neck (n=35, 46.1%) Treatment failure1 (1.4%) Treatment methods (n=75) Aneurysm distribution site(n=75)

15. Coiling failed in 1/76 = 1.3% Death rate was in 1/76 = 1.4% ( SAH consequence Complication rate was in 1/76 = 1.4% (perforation and treated without sequlae ) infarction occurred in relevant MCA territory in 2 patients, but both of them completely recovered at discharge permanent morbidity 1/76=1,4% Failure Rate Procedural complications Mortality Rate Morbidity Rate

16. Follow-up results Clinical follow-up ( avalible in all except 1) Mean 23 months ( IQR 4-105 months) None of the patients had deterioration of functional neurological outcomes (mRS, 0 – 2). No SAH 1MI death and 1stroke in basilar artery

17. Follow-up angiographies at least once at 6 – 24 months (mean, 11 months) period of follow up. 69/75 aneury sm (92%) 6 (8.6%) minor recurrences 3 (4.3%) major recurrences retreated by coiling without any complication. Mori et. al. classification

18. Case 1, catheter-assisted two- catheter technique

19. Case 2, stent-assisted coil embolization for both aneurysms

20. Case 3, HyperForm balloon assisted coiling

22. MCA aneurysms should not be allocated solely to clipping but only the large MCA aneurysms in young patients, which are likely to recur

23. Some limitations are present in this series  Small, unruptured MCA aneurysms were treated. (randomized retrospective study)  Because of the retrospective nature of this study, another limitation is selection bias  Limited number of angiographic follow- up may have lowered the recurrence rate

24. Thank you

25. Introduction  Since intracranial subarachnoid aneurysm trial (ISAT),[1] endovascular coiling has been increasingly used as first treatment option for ruptured or unruptured aneurysms that are feasible for coiling.  Intracranial subarachnoid aneurysmal trial (ISAT) proved the superiority of endovascular coiling for the treatment of ruptured intracranial aneurysms over microsurgical clipping.

26. MCA aneurysm State Of the Art Mangement  However, for the middle cerebral artery (MCA) aneurysms, endovascular coiling is less likely to be applied as routine agreement Rupture d

27. in ruptured MCA aneurysms  The most widely accepted theory presumed to be responsible for the inconvenient outcome Hematoma frequently associated with ruptured MCA aneurysm may be a cause of unfavorable outcome of coiling, because coiling itself cannot remove the hematoma.

28. MCAa Unique Morphology Gallery The aneurysm geometry unfavorable for coiling, which is frequently met in MCA aneurysms, can be another factor.

29. But other more complicated discrible morphologies could be encounterd

30. Used modified techqniue

31. Follow-up angiographies at least once at 6 – 24 months (mean, 11 months) period of follow up. 69/75 aneury sm (92%) 6 (8.6%) minor recurrences 3 (4.3%) major recurrences retreated by coiling without any complication. 60 (87.1%) major recurrences Mori et. al. classification