User Tools

Site Tools


Middle cerebral artery aneurysm


Middle cerebral artery aneurysm, represent almost a third of all the aneurysms of the anterior circulation aneurysms.

Middle cerebral artery (MCA) aneurysms constitute from 18-40% of all intracranial aneurysms 1).

Among them, those located at its so-called M1 segment (from its origin up to the bifurcation) range between 2% and 7% of all the aneurysms.

Most MCA aneurysms have been found at the division of the M1-M2 junction due to hemodynamic stress or congenital factors 2).

Only in 1.1-1.7% of cases they are located in the distal segment 3) 4) 5).

The majority of distal MCA aneurysms are located at the M2 or M3 segments 6).


Although several classifications have been proposed for the MCA aneurysms, classically they are divided into four groups: proximal, bifurcation, distal, and cortical aneurysms

While most aneurysms that originate at the MCA bifurcation or trifurcation have a saccular geometry, some MCA aneurysms may exhibit a fusiform morphology and incorporate not only the proximal MCA trunk but also major MCA branches. In contrast to saccular aneurysms, fusiform aneurysms represent a distinct subset of intracranial aneurysms with unique underlying pathological features, hemodynamic forces, anatomical distribution, as well as natural history that governs their treatment. 7).

Anatomical variations of the middle cerebral artery (MCA) are an important clinical issue, due to high prevalence of intracranial aneurysms. Anatomical variations of vessels can lead to higher shear stress, which is thought to be the main factor leading to aneurysm formation and consequently to higher prevalence of aneurysms.

The most common configuration of MCA is bifurcation before the genu with no dominating post-division trunk. Incidence of MCA aneurysms is not correlated with anatomical variations of MCA and the circle of Willis 8).


Anatomic classification scheme

Classification 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.

To 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.

Elsharkawy et al.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. 9).

Angiographic data from patients with MCA aneurysms between 1995 and 2012 were used to construct 3-dimensional models. Models were then analyzed and compared objectively by assessing the relationship between the aneurysm sac, parent vessel, and branch vessels. Aneurysms were then grouped on the basis of the similarity of their shape patterns in such a way that the in-class similarities were maximized while the total number of categories was minimized. For each category, a proposed clip strategy was developed.

From the analysis of 61 MCA bifurcation aneurysms, 4 shape pattern categories were created that allowed the classification of 56 aneurysms (91.8%). The number of aneurysms allotted to each shape cluster was 10 (16.4%) in category 1, 24 (39.3%) in category 2, 7 (11.5%) in category 3, and 15 (24.6%) in category 4.

Through the use of anatomic visual cues, MCA bifurcation aneurysms can be grouped into a small number of shape patterns with an associated clip solution. Implementing these principles within current neurosurgery training paradigms can provide a tool that allows more efficient transition from novice to cerebrovascular expert 10).

see Middle cerebral artery M1 segment aneurysm


Case series


Eighteen intracranial aneurysms, including 13 unruptured and 5 ruptured aneurysms, were treated with LVIS Jr stent-assisted coil embolization.

A total of 18 stents were successfully delivered to the target aneurysms, and the technical success rate was 100%. There was complete occlusion in 8 (44.4%) of 18 cases, neck remnants in 7 (38.9%) cases, and partial occlusion in 3 (16.7%) cases. In-stent thrombosis occurred in 1 case, and the symptoms disappeared after transvenous tirofiban injection. The modified Rankin Scale score at discharge was 0 in 14 patients, 1 in 3 patients, and 2 in 1 patient.

The LVIS Jr stent provided excellent trackability and deliverability and is safe and effective for the treatment of wide-necked MCA aneurysms with tortuous and smaller parent vessels 11).

Case reports


Lyon et al. report the presentation and successful endovascular treatment of a large, ruptured, middle cerebral artery bifurcation aneurysm in a 5-week-old girl, one of only a few reported in the literature. Clinical and radiological findings at follow-up are also presented. The authors then review the literature on aneurysmal subarachnoid hemorrhage in infants, with particular regard to outcome after either endovascular or open surgical management. They also provide recommendations for follow-up in pediatric patients whose intracranial aneurysms have been treated with coil embolization 12).


Sejkorová et al., analyzed a case of a ruptured middle cerebral artery (MCA) aneurysm for which they acquired imaging data at three time points, including at rupture. A patient with an observed MCA aneurysm was admitted to the emergency department with clinical symptoms of a subarachnoid hemorrhage. During three-dimensional (3D) digital subtraction angiography (DSA), the aneurysm ruptured again. Imaging data from two visits before rupture and this 3D DSA images at the moment of rupture were acquired, and computational fluid dynamics (CFD) simulations were performed. Results were used to describe the time-dependent changes of the hemodynamic variables associated with rupture. Time-dependent hemodynamic changes at the rupture location were characterized by decreased WSS and flow velocity magnitude. The impingement jet in the dome changed its position in time and the impingement area at follow-up moved near the rupture location. The results suggest that the increased WSS on the dome and increased low wall shear stress area (LSA) and decreased WSS on the daughter bleb with slower flow and slow vortex may be associated with rupture. CFD performed during the follow-up period may be part of diagnostic tools used to determine the risk of aneurysm rupture 13).

Ravindra et al., report the case of a previously healthy 6-month-old girl who presented with right arm and leg stiffening consistent with seizure activity. An initial CT scan of the head demonstrated acute subarachnoid hemorrhage in the basal cisterns extending into the left sylvian fissure. Computed tomography angiography demonstrated a 7 × 6 × 5-mm saccular aneurysm of the inferior M2 division of the left middle cerebral artery. The patient underwent left craniotomy and microsurgical clip ligation with wrapping of the aneurysm neck because the vessel appeared circumferentially dysplastic in the region of the aneurysm. Postoperative angiography demonstrated a small remnant, sluggish distal flow, but no significant cerebral vasospasm. Fifty-five days after the initial aneurysm rupture, the patient presented again with an acute intraparenchymal hemorrhage of the left anterior temporal lobe. Angiogram revealed a circumferentially dysplastic superior division of the M2 branch, with a new 5 × 4-mm saccular aneurysm distinct from the first, with 2 smaller aneurysms distal to the new ruptured aneurysm. Endovascular parent vessel occlusion with Onyx was performed. Genetic testing revealed a mutation of the MYH11. To the authors' knowledge, this is the first report of rapid de novo aneurysm formation in an infant with an MYH11 mutation. The authors review the patient's clinical presentation and management and comprehensively review the literature on this topic 14).

A 56-year-old woman with an unruptured, multi-lobulated MCA aneurysm, whom primarily refused surgery; therefore, she was scheduled for stent-assisted coiling. After successful deployment of the stent, it unfortunately then became snagged by the microcatheter and was pulled backwards. The subsequent surgical procedure (i.e. clipping of the MCA aneurysm) was challenging, due to the position of the dislodged stent. Such as misplacement of the stent is rarely documented: It resulted in the difficult handling of a MCA aneurysm. Aneurysms of the MCA should primarily be considered for surgical clipping. In conclusion, an increased risk for eventual surgery should be considered, in cases where endovascular treatments with stents are performed. 15).


A case of a huge intramural hematoma in a thrombosed middle cerebral artery aneurysm. A 47-year-old female patient with liver cirrhosis and thrombocytopenia presented to the neurosurgical unit with a 5-day history of headache and cognitive dysfunction. Magnetic resonance imaging and computed tomography of the brain showed a thrombosed aneurysm located in the right middle cerebral artery with a posteriorly located huge intramural hematoma mimicking an intracerebral hematoma. Imaging studies and cerebrospinal fluid analysis showed no evidence of subarachnoid hemorrhage. Angiography showed a partially thrombosed aneurysm at the origin of the right anterior temporal artery and an incidental aneurysm at the bifurcation of the right middle cerebral artery. Both aneurysms were embolized by coiling. After embolization, the thrombosed aneurysmal sac and intramural hematoma had decreased in size 4 days later and almost completely disappeared 8 months later. This is the first reported case of a nondissecting, nonfusiform aneurysm with a huge intramural hematoma, unlike that of a dissecting aneurysm 16).

1) , 5) , 9)
Elsharkawy A, Lehečka M, Niemelä M, Billon-Grand R, Lehto H, Kivisaari R, Hernesniemi J. A new, more accurate classification of middle cerebral artery aneurysms: computed tomography angiographic study of 1,009 consecutive cases with 1,309 middle cerebral artery aneurysms. Neurosurgery. 2013 Jul;73(1):94-102; discussion 102. doi: 10.1227/01.neu.0000429842.61213.d5. PubMed PMID: 23615110.
Rinne J, Hernesniemi J, Niskanen M, Vapalahti M. Analysis of 561 patients with 690 middle cerebral artery aneurysms: anatomic and clinical features as correlated to management outcome. Neurosurgery. 1996 Jan;38(1):2-11. PubMed PMID: 8747945.
Ahn JY, Han IB, Joo JY. Aneurysm in the penetrating artery of the distal middle cerebral artery presenting as intracerebral haemorrhage. Acta Neurochir (Wien). 2005 Dec;147(12):1287-90; discussion 1290. Epub 2005 Aug 29. PubMed PMID: 16133768.
Lv N, Zhou Y, Yang P, Li Q, Zhao R, Fang Y, Xu Y, Hong B, Zhao W, Liu J, Huang Q. Endovascular treatment of distal middle cerebral artery aneurysms: Report of eight cases and literature review. Interv Neuroradiol. 2016 Feb;22(1):12-7. doi: 10.1177/1591019915617317. Epub 2015 Dec 3. Review. PubMed PMID: 26637241; PubMed Central PMCID: PMC4757379.
Lee SH, Bang JS. Distal Middle Cerebral Artery M4 Aneurysm Surgery Using Navigation-CT Angiography. J Korean Neurosurg Soc. 2007 Dec;42(6):478-80. doi: 10.3340/jkns.2007.42.6.478. Epub 2007 Dec 20. PubMed PMID: 19096593; PubMed Central PMCID: PMC2588183.
Pabaney AH, Mazaris PA, Kole MK, Reinard KA. Endovascular management of fusiform aneurysm of anterior temporal artery: Technical report. Surg Neurol Int. 2015 Jul 20;6:119. doi: 10.4103/2152-7806.161239. eCollection 2015. PubMed PMID: 26290771; PubMed Central PMCID: PMC4521225.
Brzegowy P, Polak J, Wnuk J, Łasocha B, Walocha J, Popiela TJ. Middle cerebral artery anatomical variations and aneurysms - retrospective study based on computed tomography angiography findings. Folia Morphol (Warsz). 2017 Dec 13. doi: 10.5603/FM.a2017.0112. [Epub ahead of print] PubMed PMID: 29235088.
Washington CW, Ju T, Zipfel GJ, Dacey RG Jr. Middle cerebral artery bifurcation aneurysms: an anatomic classification scheme for planning optimal surgical strategies. Neurosurgery. 2014 Mar;10 Suppl 1:145-53; discussion 153-5. doi: 10.1227/NEU.0000000000000250. PubMed PMID: 24226424.
Feng Z, Li Q, Zhao R, Zhang P, Chen L, Xu Y, Hong B, Zhao W, Liu J, Huang Q. Endovascular Treatment of Middle Cerebral Artery Aneurysm with the LVIS Junior Stent. J Stroke Cerebrovasc Dis. 2015 Jun;24(6):1357-62. doi: 10.1016/j.jstrokecerebrovasdis.2015.02.016. Epub 2015 Apr 4. PubMed PMID: 25851343.
Lyon KA, Arrey EN, Haider AS, Jeevan DS, Benardete EA. Endovascular treatment of a large ruptured middle cerebral artery bifurcation aneurysm in a 5-week-old infant: case report. J Neurosurg Pediatr. 2017 Aug 4:1-7. doi: 10.3171/2017.5.PEDS17116. [Epub ahead of print] PubMed PMID: 28777036.
Sejkorová A, Dennis KD, Švihlová H, Petr O, Lanzino G, Hejčl A, Dragomir-Daescu D. Hemodynamic changes in a middle cerebral artery aneurysm at follow-up times before and after its rupture: a case report and a review of the literature. Neurosurg Rev. 2016 Nov 24. [Epub ahead of print] PubMed PMID: 27882440.
Ravindra VM, Karsy M, Schmidt RH, Taussky P, Park MS, Bollo RJ. Rapid de novo aneurysm formation after clipping of a ruptured middle cerebral artery aneurysm in an infant with an MYH11 mutation. J Neurosurg Pediatr. 2016 Oct;18(4):463-470. PubMed PMID: 27367753.
Al-Schameri AR, Lunzer M, Daller C, Kral M, Killer M. Middle cerebral artery aneurysm surgery after stent misplacement: A case report. Interv Neuroradiol. 2016 Feb;22(1):49-52. doi: 10.1177/1591019915617313. Epub 2015 Nov 19. PubMed PMID: 26590180.
Kim HJ, Lee SW, Lee TH, Kim YS. Huge Intramural Hematoma in a Thrombosed Middle Cerebral Artery Aneurysm: A Case Report. J Cerebrovasc Endovasc Neurosurg. 2015 Sep;17(3):234-8. doi: 10.7461/jcen.2015.17.3.234. Epub 2015 Sep 30. PubMed PMID: 26523258; PubMed Central PMCID: PMC4626348.
middle_cerebral_artery_aneurysm.txt · Last modified: 2017/12/16 12:00 by administrador