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Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (<jats:italic>p<\/jats:italic>= 0.048, <jats:italic>p<\/jats:italic>=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (<jats:italic>p<\/jats:italic>= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (<jats:italic>p<\/jats:italic>= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants\u2019 rate and improvement in both short- and long-term patient\u2019s outcome.<\/jats:p>","DOI":"10.1007\/s10143-023-02099-w","type":"journal-article","created":{"date-parts":[[2023,8,3]],"date-time":"2023-08-03T10:01:56Z","timestamp":1691056916000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["Has intraoperative neuromonitoring changed the surgery for unruptured middle cerebral artery aneurysms? A retrospective comparative study"],"prefix":"10.1007","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3935-9451","authenticated-orcid":false,"given":"Benjamin","family":"Skrap","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5065-430X","authenticated-orcid":false,"given":"Rina","family":"Di Bonaventura","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0656-7908","authenticated-orcid":false,"given":"Michele","family":"Di Domenico","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4080-2492","authenticated-orcid":false,"given":"Carmelo Lucio","family":"Sturiale","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4186-4476","authenticated-orcid":false,"given":"Anna Maria","family":"Auricchio","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4954-9817","authenticated-orcid":false,"given":"Rosario","family":"Maugeri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6309-8963","authenticated-orcid":false,"given":"Giuseppe Roberto","family":"Giammalva","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1685-5209","authenticated-orcid":false,"given":"Domenico Gerardo","family":"Iacopino","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4489-7564","authenticated-orcid":false,"given":"Alessandro","family":"Olivi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8551-0357","authenticated-orcid":false,"given":"Enrico","family":"Marchese","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8783-2974","authenticated-orcid":false,"given":"Alessio","family":"Albanese","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,8,3]]},"reference":[{"issue":"9","key":"2099_CR1","doi-asserted-by":"publisher","first-page":"928","DOI":"10.1056\/NEJMra052760","volume":"355","author":"JL Brisman","year":"2006","unstructured":"Brisman JL, Song JK, Newell DW (2006) (2006) Cerebral aneurysms. 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