Microsurgical clipping remains a viable option for the treatment of coilable ruptured middle cerebral artery aneurysms in the endovascular era.

Although many institutions increasingly perform endovascular coiling instead of microsurgical clipping as the primary treatment for ruptured aneurysms, there remains ongoing debate regarding the optimal treatment strategy for ruptured middle cerebral artery (MCA) aneurysms. Therefore, we compared the outcomes of clipping and coiling for treating ruptured MCA aneurysms. A total of 155 ruptured MCA aneurysms that were deemed eligible for both clipping and coiling were retrospectively reviewed. We compared patient characteristics, radiological results, clinical outcomes, and perioperative complications between patients who received clipping and those receiving coiling. Furthermore, we analyzed the potential risk factors for perioperative complications that differed between the two groups. 59 (38.1%) aneurysms were treated using coiling, and 96 (61.9%) received clipping. The clipping group showed a significantly higher rate of immediate complete occlusion and a lower rate of neck remnants compared with the coiling group (p = 0.006). These radiological results persisted at the 12-month angiographic follow-up, with a significantly higher complete occlusion rate (p = 0.038) and a lower recanalization rate (p = 0.033) in the clipping group. The clinical outcomes were comparable between the two groups. Patients treated with coiling showed a higher rate of permanent shunting than those treated with clipping (18.6% vs. 8.3%, p = 0.058). Coiling was independently associated with shunt-dependent hydrocephalus in multivariate analysis. Microsurgical clipping provides comparable clinical outcomes, better occlusion, and superior durability for treating ruptured MCA aneurysms compared with endovascular coiling. Therefore, clipping remains a viable option for treating ruptured MCA aneurysms, even in aneurysms suitable for coiling.