Abstract
Middle cerebral aneurysms can develop from a variety of locations but most aneurysms occur at M_1 bifurcation, although the origin of the anterior temporal artery, the lenticulostriate artery, and the area distal to the M_2 segments are also likely sites. There are two major surgical approaches to consider for an aneurysm at the M1 bifurcation : the proximal approach, which proceeds from the internal carotid, the M_1, and the bifurcation : and the distal approach, which proceeds from the M_2 directly to the M_1 bifurcation and the aneurysm. We use both approaches interchangeably, even in one patient, whichever was considered safer and less traumatic to the brain. Body clipping is a major surgical requirement for a wide-necked aneurysm, and a combination of the most suited multiple clips should be used on aneurysms with arterial branching. Temporary clips should be limited to cases of a premature aneurysmal rupture, or if an aneurysm appears imminent, or when puncturing the aneurysm to reduce its mass. In all instances, however, the brain must be protected before applying any temporary clip. Although early removal of the blood clot is the best way to prevent the occurrence of a vasospasm, it is impossible to surgically remove a clot sited deeply in the insular cistern. The intrathecal use of thrombolytic agents seems to be promising procedure, provided that their side effect (bleeding) can be controlled. However, no single drug treatment has been found successful. Thus, a combination of several drugs with different mechanisms of action may have to be used to abolish the vasospasm.
