SURGICAL-MANAGEMENT OF MIDDLE CEREBRAL-ARTERY ANEURYSMS - EXPERIENCE WITH TRANSSYLVIAN AND SUPERIOR TEMPORAL GYRUS APPROACHES

BACKGROUND Middle cerebral artery (MCA) aneurysms are typically approached surgically using one of three basic techniques. The sylvian fissure can be opened in one of two ways; either from medial to lateral or from lateral to medial, Alternatively, an incision in the superior temporal gyrus with subpial resection can be used to expose the MCA branches and aneurysm neck. METHODS We reviewed 65 middle cerebral aneurysms in 62 patients operated on over a 5-year interval where a choice of operative approach was made based on preoperative evaluation of available radiological studies, RESULTS The superior temporal gyrus was used when intraparenchymal hematoma was present in the temporal lobe or when the length of the middle cerebral artery trunk was long (average length 2.44 +/- 0.41 SE cm), This approach was used in 20 operations on 22 aneurysms. The sylvian fissure approach was used in cases where the middle cerebral artery main trunk was short (1.32 +/- 0.41 SE cm) or the direction of the aneurysm was favorable. This approach was used in 38 operations. In 4 operations (5 aneurysms) we combined the two approaches to remove dot, obtain adequate exposure, and secure control of the proximal MCA, CONCLUSIONS In most cases of MCA aneurysms the decision as to which surgical approach to use is made preoperatively depending on the presence of intraparenchymal clot, size of aneurysm, direction of aneurysm, and length of the proximal middle cerebral artery.