ESPITE the growing number of intracranial aneu- rysms amenable to endovascular repair, those of the MCA remain a particular challenge. Treatment with coil occlusion is often risky and incomplete because these dilations are often wide-necked and incorporate one of the M 2 branches. In contrast, the surgical exposure and tech- nique required to clip an MCA aneurysm properly through a craniotomy are often straightforward factors for the ex- perienced cerebrovascular surgeon. 15 Middle cerebral artery aneurysms in patients who present with SAH and signif- icant vasospasm represent a unique management dilem- ma. Although the lesion is often anatomically more suit- ed to clip application, severe vasospasm, particularly if it is symptomatic, is considered a contraindication to the pro- cedure. 10,16 Endovascular repair that either jeopardizes the M 2 branches or allows for only partial occlusion is also not ideal, especially in young patients in whom a partially open aneurysm may pose a long-term risk of repeated rupture. The management of aneurysmal SAH in patients pre- senting with vasospasm is controversial. Many factors, in- cluding clinical grade, patient age, aneurysm location, and whether the vasospasm is symptomatic, play a role in de- cision making. Different treatment strategies have been re- ported, including conservative treatment, waiting for the vasospasm to resolve, microsurgical clip application im- mediately followed by endovascular vasospasm treatment (angioplasty and/or intraarterial vasodilating vessels), 11 or endovascular obliteration of the aneurysm combined with simultaneous vasospasm treatment. 13 In this report, we de- scribe two patients who presented with ruptured MCA an- eurysms associated with severe local vasospasm and who were successfully treated using an intentionally staged en- dovascular and microsurgical treatment strategy. A com- bined dual modality approach was planned, which involved intentional partial coil occlusion of the aneurysmal dome, balloon angioplasty of the stenotic vessel segments, and J Neurosurg 101:154–158, 2004 154 Intentional partial coil occlusion followed by delayed clip application to wide-necked middle cerebral artery aneurysms in patients presenting with severe vasospasm Report of two cases JONATHAN L. BRISMAN, M.D., CHAN ROONPRAPUNT , M.D., PH.D., JOON K. SONG, M.D., Y ASUNARI NIIMI, M.D., A VI SETTON, M.D., ALEJANDRO BERENSTEIN, M.D., AND EUGENE S. FLAMM, M.D. Center for Endovascular Surgery; Department of Neurosurgery; Hyman-Newman Institute for Neurology and Neurosurgery, Beth Israel Medical Center, New York; and Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, New York √ The treatment of ruptured cerebral aneurysms in patients presenting with vasospasm remains a particular challenge. The authors treated two patients harboring Hunt and Hess Grade 1 subarachnoid hemorrhages from middle cerebral artery (MCA) aneurysms associated with severe local angiographically demonstrated yet asymptomatic vasospasm on presenta- tion. Because both aneurysms had wide necks and were located at the MCA bifurcation, they were believed to be anatom- ically suitable for microsurgical clip application. Severe M 1 vasospasm was believed to be a relative contraindication to open surgery, however. An intentionally staged endovascular and microsurgical treatment strategy was planned in each patient. Partial coil oc- clusion of the aneurysmal dome was performed to prevent the lesion from rebleeding and was followed by balloon angio- plasty of the spastic vessel. Early treatment of the severe spasm appeared to prevent significant delayed neurological isch- emic deficit. Following resolution of the vasospasm, definitive clipping of the aneurysms was performed on Day 13 post embolization. One patient had a good clinical recovery and was discharged without neurological deficit. The other patient’s hospital course was complicated by the occurrence of a postoperative posterior temporal infarct requiring partial temporal lobectomy, although she eventually had a good recovery with only a small visual field deficit. Based on data obtained in these two patients, one can infer that ruptured wide-necked MCA aneurysms associated with severe local vasospasm may best be treated using a staged combined treatment plan. Delayed clip application might be performed more safely 4 to 6 weeks postocclusion, or later, than at 2 weeks. KEY WORDS • coil occlusion • clip application • middle cerebral artery aneurysm • vasospasm • angioplasty D J. Neurosurg. / Volume 101 / July, 2004 Abbreviations used in this paper: CT = computerized tomogra- phy; ICP = intracranial pressure; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage.