• Tim E Darsaut, Michael B Keough, Abdelaziz Sagga, Vivien K Y Chan, Ange Diouf, William Boisseau, Elsa Magro, Marc Kotowski, Daniel Roy, Alain Weill, Daniela Iancu, Michel W Bojanowski, Chiraz Chaalala, Alain Bilocq, Laurent Estrade, Jean-Paul Lejeune, Nicolas Bricout, Felix Scholtes, Didier Martin, Bernard Otto, J Max Findlay, Michael M Chow, Cian J O'Kelly, Robert A Ashforth, Jeremy L Rempel, Howard Lesiuk, John Sinclair, David J Altschul, Fuat Arikan, Francois Guilbert, Miguel Chagnon, Behzad Farzin, Guylaine Gevry, and Jean Raymond.
• Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada.
• World Neurosurg. 2021 May 1; 149: e521-e534.

ObjectiveThere are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials.MethodsBoth trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded.ResultsThere were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling.ConclusionsRandomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.Copyright © 2021 Elsevier Inc. All rights reserved.

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