Flow Diversion vs. Coiling for Large and Giant Intracranial Aneurysms: A Systematic Review and Meta-Analysis

Area of Science:

• Neurosurgery
• Interventional Neurology
• Vascular Neurology

Background:

• Large (≥10 mm) and giant (≥25 mm) intracranial aneurysms present significant management challenges due to high rupture risk and procedural complexities.
• Endovascular approaches like flow diversion (FD) offer promise, but comparative data on safety and efficacy against traditional coiling are limited.

Purpose of the Study:

• To compare the safety and efficacy of flow diversion (FD) versus coiling for treating large and giant intracranial aneurysms.
• To evaluate outcomes including aneurysm recurrence, occlusion rates, clinical outcomes, and complications.

Main Methods:

• A systematic review and meta-analysis adhering to PRISMA guidelines.
• Included studies published between January 2000 and March 2025 from major databases (PubMed, EMBASE, Scopus, Web of Science).
• Assessed outcomes such as recurrence, complete occlusion, clinical outcomes, complications, and mortality, calculating odds ratios (ORs) with 95% confidence intervals (CIs).

Main Results:

• The analysis included 1893 patients (1256 FD, 637 Coiling) across 33 studies.
• Flow diversion significantly reduced aneurysm recurrence compared to coiling (8% vs. 27%, p=0.0001) and showed a trend toward higher complete occlusion rates (p=0.0571).
• Flow diversion was associated with a modestly increased rate of hemorrhagic complications (p=0.0495), with no significant differences in other major complications, clinical outcomes, or mortality.

Conclusions:

• Both FD and coiling are effective and safe for large/giant intracranial aneurysms.
• FD demonstrates superior recurrence rates and a trend towards better occlusion, with comparable overall safety but a slightly elevated hemorrhagic risk.
• FD is emerging as a preferred first-line treatment for unruptured large and giant aneurysms, while coiling remains crucial for ruptured cases or anatomical limitations.