Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison.

ABSTRACT Objective There is little randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from MCA aneurysm patients enrolled in the CURES and ISAT-2 randomized trials. Methods Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-25 mm UIAs, and ISAT-2 includes RA patients for whom uncertainty remains after ISAT. The primary outcome measure of CURES is Treatment Failure: i) Failure to treat the aneurysm, ii) Intracranial hemorrhage during follow-up, or iii) Residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (mRS>2) at 1 year. One year angiographic outcomes are systematically recorded. Results There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 UIA patients have been treated, 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to Treatment Failure in 3/42 (7%;95%CI:0.02-0.19) for clipping and 13/48 (27%;95%CI:0.17-0.41) for coiling (P=0.025). All 71 RA patients have been treated. In ISAT-2, ruptured MCA aneurysm patients managed surgically were dead or dependent (mRS>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 UIA and 62 RA patients. Complete aneurysm occlusion was found in 30/40 (75%;95%CI:0.60-0.86) UIA patients allocated clipping, and 14/40 (35%;95%CI:0.22-0.50) UIA patients allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%;95%CI:0.54-0.83) RA patients allocated clipping, and 15/28 (54%;95%CI:0.36-0.70) RA patients allocated coiling. Conclusions Randomized data from two trials shows that better efficacy may be obtained with surgical management of MCA aneurysm patients. Clinical Trial Registration http://www.clinicaltrials.gov. Unique identifiers: NCT01139892, NCT01668563.