Early Surgical Management of Middle Cerebral Artery Aneurysms Associated With Intracerebral Hematomas: The Uludag ˘ University Experience Hasan Kocaeli, MD, Ender Korfalı, MD, Mehmet Savran, MD, Selc¸uk Yılmazlar, MD, Ahmet Bekar, MD, and S¸eref Dog ˘an, MD Abstract: In this case series study, the surgical outcomes of 29 patients with intracerebral hematomas resulting from the rupture of middle cerebral artery aneurysms that were operated on within the first 12 hours after rupture were retrospectively analyzed. Preoperative cerebral angiography could be obtained in 12 (41.3%) of our patients. Outcome was assessed according to the Glasgow Outcome Scale at 6 months after surgery. Overall mortality was 48%. Of 12 patients in good preoperative condition, 6 (50%) had a favorable outcome (Glasgow Outcome Scale, 4 to 5), whereas of the 17 patients in poor preoperative condition only 1 (5.8%) had a favorable outcome (P = 0.042). Our results suggest that despite early surgical treatment of patients with ruptured middle cerebral artery aneurysms associated with massive intracerebral hematoma, mortality continues to be high in patients with poor preoperative grades. Key Words: aneurysm, middle cerebral artery, intracerebral hematoma, clipping, sylvian fissure (Neurosurg Q 2011;21:26–32) A neurysm rupture results in an intracerebral hematoma (ICH) in 4% to 42.6% of patients and is a predictor of unfavorable outcome. 1–6 Middle cerebral artery (MCA) aneurysms are the most common source of ICH and early surgical evacuation of large ICH is believed to improve the outcome. 2,5–16 Earlier studies report over 80% mortality with conservative treatment, 10,17 whereas evacuation of hematoma without aneurysm clipping has been reported to be associated with 75% to 100% mortality. 16 Even with aneurysm clipping and hematoma aspiration, the reported mortality rate ranges from 21% to 85%. 3,5,8,10,14,17 Owing to the technical difficulties of coiling the usually complex MCA aneurysms, microsur- gical clipping continues to be a valid alternative, especially for patients having MCA aneurysms with associated large ICH. 3,8,14,18 We report here on our experiences in a series of 29 patients diagnosed with MCA aneurysms associated with an ICH Z30 cm 3 who were operated on within the first 12 hours after rupture. MATERIALS AND METHODS Patient Population Between 1990 and 2006, 852 patients with cerebral aneurysms were surgically treated at the neurosurgery department of Uludag˘ , University Hospital, Bursa, Turkey. Of these, 29 (3.4%) were diagnosed with MCA aneurysms that caused an ICH with a volume of Z30 cm 3 . Inclusion criteria included patients between 18 and 65 years of age, presentation within the first 12 hours, and computed tomography (CT) evidence of subarachnoid hemorrhage (SAH) associated with an ICH Z30 cm 3 . Patients were excluded if they were on therapeutic anticoagulation or had a Glasgow Coma Scale score of 3 without spontaneous respirations. The clinical status of each patient at admission was graded according to Hunt and Hess (H-H) classifica- tion. 19 We considered patients to have a good preoperative condition if their H-H grade was I-III, whereas patients with grade IV or V were considered as poor grade. The volume of the ICH was estimated from the CT using the ABC/2 method. 20 The types of ICH were classified into 2 groups according to CT findings on admission: (1) intratemporal ICH and (2) intrasylvian ICH. Microsurgical clipping was the only treatment modality used for the patients in this study. During the study period, CT angiography (CTA) was not available at our institution and endovascular intervention was not an option because of lack of equipment and operators. Preoperative cerebral angiography could be obtained in 12 (41.3%) of our patients. In all cases, aneurysm clipping and ICH evacua- tion was performed through a frontotemporal craniotomy. Acute hydrocephalus was treated by external cerebrospinal fluid diversion. Surgical Technique and Postoperative Care Our surgical technique involved a frontotemporal craniotomy with sufficient dural opening followed by partial removal of the clot distant to the aneurysm. After Copyright r 2011 by Lippincott Williams & Wilkins From the Department of Neurosurgery, Uludag˘ University School of Medicine, Bursa, Turkey. This study has been presented in part at the XXI Annual Meeting of Turkish Neurosurgical Society held in May 2007 in Antalya, Turkey. The authors of this study have no conflicts of interest. Reprints: Hasan Kocaeli, MD, Department of Neurosurgery, Uludag˘ University School of Medicine, Go¨ru¨kle Campus, 16059, Bursa, Turkey (e-mail: hasankocaeli@yahoo.com; hkocaeli@uludag.edu.tr). ORIGINAL ARTICLE 26 | www.neurosurgery-quarterly.com Neurosurg Q  Volume 21, Number 1, February 2011