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The main aim of this study is to present a proposed grading system to preoperatively predict the difficulties in this approach. The clinical files, radiological studies, operation records, intraoperative video recordings, complications and outcomes of 31 patients were retrospectively reviewed. In the first part of this study (2001\u20132010), we operated on 22 patients with bMCA aneurysms and were able to clip the contralateral aneurysm via unilateral approach in only 12 cases (54.5%). Considering our experience from the surgery of these patients, we identified 5 parameters that reveal surgical difficulties. In the second part of the study (2011\u20132023), considering these 5 parameters, 20 patients were selected for unilateral approach and bilateral aneurysms could be clipped in 19 patients (95%). As a result, 26 of 31 patients (83.9%) were discharged with a favorable outcome (mRS 0\u20132, excellent-good). Intraoperative rupture occurred in one patient. Based on our experience, we developed a grading system with a total of 10 points by assigning points according to the degree of difficulty of each parameter and classified surgical difficulty as follows: 0\u20131 low difficulty, 2\u20133 moderate difficulty, 4\u20136 high difficulty and 7\u201310 very high difficulty. Patients with bMCA aneurysms can be operated via unilateral approach in experienced hands in properly selected cases. This grading system may help the neurosurgeon in this selection by preoperatively predicting intraoperative difficulties. This study is a completely retrospective file scan. This is not a clinical trial. Clinical trial number: not applicable.<\/jats:p>","DOI":"10.1007\/s10143-025-03634-7","type":"journal-article","created":{"date-parts":[[2025,6,11]],"date-time":"2025-06-11T23:29:35Z","timestamp":1749684575000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Unilateral approach to bilateral middle cerebral artery aneurysms: a large series and a proposed grading system to predict technical difficulties"],"prefix":"10.1007","volume":"48","author":[{"given":"Servet","family":"Inci","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sacide","family":"Kalaycioglu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,6,12]]},"reference":[{"key":"3634_CR1","doi-asserted-by":"publisher","first-page":"774","DOI":"10.1016\/j.wneu.2017.09.078","volume":"108","author":"V Acik","year":"2017","unstructured":"Acik V, Cavus G, Bilgin E et al (2017) Surgical treatment of mirror middle cerebral artery aneurysms: bilateral and unilateral approach. 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In our hospital, all patients give consent during hospitalization: \u2018I consent to the use and dissemination of clinical findings, examinations, treatment and outcome information about my disease for scientific studies, provided that all my identity information remains confidential\u2019. In addition, patients who will undergo surgery give consent before surgery by stating \u2018I agree to share the documents related to my disease with other physicians in educational meetings and other academic activities\u2019. Informed consent was provided from every human participants included in the study.This study is a completely retrospective file scan. According to the rules in our country, Human Ethics approval is not required for purely retrospective file scans. But informed consent was provided from every human participants included in the study.The data in this study were collected in accordance with the Helsinki Declaration.According to the rules in our country, Internal Review Board (IRB) approval is not required for purely retrospective file scans.This study is not a clinical trial. Clinical trial number: not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing \u0131nterests"}}],"article-number":"504"}}