Untangling the debate: a meta-analysis comparing clipping versus coiling in ruptured middle cerebral artery aneurysms

The optimal treatment strategy for ruptured middle cerebral artery (MCA) aneurysms remains debated, with microsurgical clipping offering superior occlusion and stroke rates in exchange for a more invasive experience. Although several landmark trials showed an overall benefit for coiling as compared to clipping, MCA aneurysms were underrepresented, and more granular data regarding the impact of the MCA morphology and risk factors have complicated interpretation of preceding data. We sought to perform a comprehensive contemporary meta-analysis comparing clinical and radiographic outcomes after clipping and coiling of ruptured MCA aneurysms. A PRISMA-compliant systematic review and meta-analysis was conducted using MEDLINE and EMBASE through March 2026. Studies reporting occlusion rates, clinical outcomes, and complications for both clipping and coiling in ruptured MCA aneurysms were included. Statistical analysis was performed using a random-effects model with risk ratios (RR) and odds ratios (OR) reported with 95% confidence intervals (CI). Heterogeneity was assessed via Cochran's Q test and I² statistic. A total of twelve studies met inclusion criteria, representing a total 1,309 patients (899 clipping, 410 coiling). Clipping and coiling had similar WFNS IV-V (OR = 1.32, 95%CI = 0.74-2.37, p = 0.28) and modified Fisher grade IV (OR = 1.17, 95%CI = 0.7-1.95, p = 0.47) rates at presentation. Clipping was associated with significantly higher rates of complete occlusion (Raymond-Roy grade I; RR = 1.45, 95%CI = 1.25-1.68, p < 0.0001). Retreatment rates were significantly lower following clipping (OR = 0.44, 95%CI = 0.2-0.95, p = 0.038). No significant difference was found in rates of intraoperative rupture, mRS 0-2 at discharge or 12 months, rebleeding, postoperative stroke, vasospasm, need for secondary decompressive craniectomy, shunt-dependent hydrocephalus, or mortality. Complete occlusion and retreatment outcomes for ruptured MCA aneurysm are superior after clipping as compared to coiling. Other clinical outcomes including stroke, vasospasm, or hydrocephalus, were not significantly different between treatment modalities. Given the evolving nature of endovascular techniques and the selection bias inherent to a meta-analysis of observational studies, future studies incorporating propensity-matched techniques may inform updated treatment guidelines and optimize patient outcomes.