Microsurgical clipping versus endovascular therapy for distal anterior cerebral artery aneurysms: A meta-analysis of double-armed comparative studies

Distal anterior cerebral artery (DACA) aneurysms are rare but pose significant treatment challenges due to their deep location and fragile morphology. Both microsurgical clipping (MS) and endovascular therapy (EVT) have evolved, yet optimal management remains debated. To compare the safety and efficacy of MS versus EVT for ruptured and unruptured DACA aneurysms using data from double-armed studies. A meta-analysis was conducted according to PRISMA guidelines. Twelve double-armed comparative studies with ≥ 3 patients per arm were included. Outcomes were synthesized using risk ratios (RR) as the primary effect measure and risk differences (RD) for absolute effect size. For ruptured DACA aneurysms, MS showed superior occlusion rates (RR: 0.71 [0.55–0.93]). EVT showed higher aneurysm recurrence (RR 4.47 [1.47–13.58]); accordingly, MS had lower recurrence. Compared to MS, EVT had a lower intraprocedural rupture risk (RR 0.29 [0.15–0.59]), reduced 90-days mortality (RR: 0.47 [0.22–1.00]), better functional outcomes at discharge (RR: 1.26 [1.06–1.49]) and at last follow up (RR: 1.24 [1.12–1.38]). No significant differences were found in vasospasm, ischemic stroke, or hydrocephalus. The unruptured DACA aneurysms group did not show significant differences between MS and EVT. While MS still offers durable occlusion, EVT has significantly evolved to achieve superior short-term outcomes in ruptured DACA aneurysms, including lower mortality and improved functional recovery. Treatment should be individualized based on rupture status, anatomy, and institutional expertise.