Endovascular coiling vs. microsurgical clipping for ruptured anterior circulation aneurysms: an updated meta-analysis...

While both endovascular coiling and microsurgical clipping are extensively used and recognized procedures, they have different advantages and disadvantages in terms of procedural risks, long-term neurological prognosis, and complications. This meta-analysis compares the effectiveness and safety of endovascular coiling with microsurgical clipping in patients with ruptured anterior circulation aneurysms.

A comprehensive search was conducted on PubMed, Web of Science, Scopus, and Cochrane Library until February 2025. Studies comparing endovascular coiling and microsurgical clipping for managing ruptured anterior circulation aneurysms were retrieved. The main endpoint was all-cause mortality. Secondary endpoints included good outcomes, poor outcome complications, and operative outcomes. The risk ratios (RR) and mean differences (MD) with their 95% confidence interval (CI) were computed employing random-effects models.

34 studies, incorporating 4,107 patients, met the inclusion criteria. Coiling revealed a higher risk of all-cause mortality (RR: 1.291 with 95% CI [1.054, 1.582]), primarily in short-term follow-up (RR: 1.50 with 95% CI [1.15, 1.95]). However, no significant differences were observed in mortality rates according to the specific aneurysm location. Neither poor outcome (RR: 0.90 with 95% CI [0.74, 1.08]) nor good outcome (RR: 1.06 with 95% CI [0.98, 1.14]) differed significantly between treatments. Coiling demonstrated reduced risks of intraoperative rupture (RR: 0.55 with 95% CI [0.34, 0.88]), ischemic infarction (RR: 0.76 with 95% CI [0.6, 0.97]), and seizure (RR: 0.42 with 95% CI [0.18, 0.97]). However, coiling was associated with lower complete occlusion rates (RR: 0.76 with 95% [CI 0.66, 0.87]) and higher incomplete occlusion (RR: 2.98 with 95% CI [2.03, 4.38]).

Endovascular coiling for ruptured anterior circulation aneurysms is associated with fewer perioperative complications, including reduced risks of intraoperative rupture, ischemic infarction, and seizures. However, it carries a higher risk of short-term mortality, lower rates of complete occlusion, and higher rates of incomplete occlusion compared with microsurgical clipping. Despite these differences, both techniques achieve comparable long-term functional outcomes, supporting an individualized, patient-centered treatment approach.