OBJECTIVE: In recent years the endovascular treatment of intracranial aneurysms 
(coiling) has progressively gained recognition, particularly after the 
publication of the International Subarachnoid Aneurysm Trial (ISAT) in 2002. 
Despite the fact that in ISAT middle cerebral artery (MCA) aneurysms were 
clearly underrepresented, the study is often used as an argument to favor 
coiling above surgery in MCA aneurysms. Taken into account that MCA aneurysms 
are very well accessible for surgery, a contemporary assessment of the benefits 
of a preferred surgical strategy for MCA aneurysms was performed in a tertiary 
neurovascular referral center.
METHODS: A prospectively kept single-center database of 151 consecutive patients 
with an MCA aneurysm was reviewed over a 6-year period (2001-2006). Long-term 
follow-up after surgical treatment of a ruptured MCA aneurysm was obtained in 74 
out of 77 (96%) patients. The outcome was compared with relevant series in the 
literature.
RESULTS: After a mean follow-up of 4.7 years, 59 out of 74 surgically treated 
patients (80%) with a ruptured MCA aneurysm had a good outcome (mRankin 0-2). 
All patients with an unruptured MCA aneurysm also had a good outcome after 
clipping. This is well-matched with the findings of the literature search, and 
competitive with the endovascular results.
CONCLUSION: Surgical clipping is recommended as the principal treatment strategy 
for MCA aneurysms. This is not only ethically defendable in view of the surgical 
results but also in line with a strategy to maintain surgical experience within 
centralized neurovascular centers.