• Ahmed Elsharkawy, Martin Lehečka, Mika Niemelä, Romain Billon-Grand, Hanna Lehto, Riku Kivisaari, and Juha Hernesniemi.
• Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland. ahmed.elsharkawy@hus.fi
• Neurosurgery. 2013 Jul 1;73(1):94-102; discussion 102.

BackgroundClassification of middle cerebral artery (MCA) aneurysms is sometimes difficult because the identification of the main MCA bifurcation, the key for accurate classification of MCA aneurysms, is inconsistent and somewhat subjective.ObjectiveTo use the meeting point of the M1 and M2 trunks as an objective, generally accepted, and angiographically evident hallmark for identification of MCA bifurcation and more accurate classification of MCA aneurysms.MethodsWe reviewed the computed tomographic angiography data of 1009 consecutive patients with 1309 MCA aneurysms. The M2 trunks were followed proximally until their meeting with the M1 trunk at the main MCA bifurcation. The aneurysms were classified according to their relative location: proximal, at, or distal to the MCA bifurcation. The M1 aneurysms were further subgrouped into M1 early cortical branch aneurysms and M1 lenticulostriate artery aneurysms, extending the classic 3-group classification of MCA aneurysms into a 4-group classification.ResultsThe main MCA bifurcation was the most common location for MCA aneurysms, harboring 829 aneurysms (63%). The 406 M1 aneurysms comprised 242 M1 early cortical branch aneurysms (60%) and 164 M1 lenticulostriate artery aneurysms (40%). We found 106 MCA aneurysms (8%) at the origin of large early frontal branches simulating M2 trunks liable to be misclassified as MCA bifurcation aneurysms. Even though 51% of the 407 ruptured MCA aneurysms were associated with an intracerebral hematoma, this did not affect the classification.ConclusionStudying MCA angioarchitecture and applying the 4-group classification of MCA aneurysms is practical and facilitates the accurate classification of MCA aneurysms, helping to improve surgical outcome.

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