Ruptured middle cerebral artery aneurysm treatment with primary coiling versus clipping: A comparative meta-analysis

Traditionally treated with microsurgical clipping, the treatment preference for intracranial aneurysms has shifted towards endovascular coiling. However, the choice between endovascular coiling and microsurgical clipping as the primary treatment strategy for ruptured middle cerebral artery (MCA) aneurysms remains disputed. We conducted a systematic review and meta-analysis to compare the radiological and clinical outcomes of ruptured MCA aneurysms treated with primary coiling and microsurgical clipping.

An extensive literature search was performed across PubMed, Embase, and Cochrane databases through August 2025. The primary outcomes of our study include the mRS scores at discharge and at long-term follow-up. Secondary outcomes include aneurysm occlusion post-procedurally or at discharge, and at long-term follow-up. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model.

A total of 5 studies, involving 984 patients (coiling = 449, clipping = 535) were included. There are no significant differences in good functional outcome (mRS 0-2) among ruptured MCA aneurysms treated with either endovascular coiling or microsurgical clipping at discharge (RR: 1.04; CI: 0.93-1.18; p = 0.473) and long-term follow-up (RR: 1.07; CI: 0.95-1.20; p = 0.245), even though endovascular coiling is associated with lower rates of complete aneurysm occlusion at discharge (RR: 0.66; CI: 0.54-0.82; p < 0.001) and long-term follow-up (RR: 0.76; CI: 0.66-0.89; p < 0.001).

Our meta-analysis suggests that while microsurgical clipping and primary coiling of ruptured MCA aneurysms had similar functional outcomes, clipping is associated with higher rates of complete aneurysm occlusion. Future studies with larger cohorts with prospective data, as well as studies that include more contemporary endovascular technologies and techniques, are warranted.