More than meets the eye: A meta-analysis of visual outcomes following clipping, coiling, and flow diversion for visually symptomatic paraclinoid aneurysms

The optimal strategy for preserving or improving visual function in patients with visually symptomatic paraclinoid aneurysms remains unclear. We report a novel meta-analysis comparing visual outcomes after clipping, coiling, and flow diversion.

A PRISMA-compliant systematic review was performed across MEDLINE and Embase through May 2026. Visual outcomes were classified as improved, unchanged, or worsened in patients with baseline visual symptoms, and as new transient or permanent deficits in those without. A random effects meta-analysis of 21 studies was conducted with supplementary sensitivity analyses, with all effect sizes expressed as odds ratios (OR). Risk of bias was assessed with the ROBINS-I tool, and the certainty of evidence was rated with the GRADE framework.

As compared to coiling, clipping was significantly associated with both visual improvement (OR 2.28; 95 % CI: 1.19-4.37; p = 0.013) and a decreased risk of unchanged visual deficits (OR 0.35; 95 % CI: 0.18-0.68; p = 0.002). Sensitivity analyses did not reproduce this finding, save for the comparison between clipping and stent-assisted coiling. Both clipping (OR 19.53; 95 % CI: 2.05-186.34; p = 0.010) and coiling (OR 10.75; 95 % CI: 1.08-106.48; p = 0.042) were significantly associated with increased visual worsening compared to FD, based on data derived from only 2 studies. Across 16 studies, clipping significantly increased the risk of new visual deficits versus coiling (OR 2.28; 95 % CI: 1.21-4.33; p = 0.011) and permanent deficits (OR 3.10; 95 % CI: 1.40-6.87; p = 0.005); these findings only lost significance when excluding studies with aneurysms < 7  mm or studies restricted to ophthalmic artery aneurysms. The certainty of evidence overall was graded very low with the GRADE framework.

Clipping may offer the best chance of visual improvement in selected patients with symptomatic paraclinoid aneurysms, though this finding proved fragile across sensitivity analyses. Clipping also appears to carry an increased risk of new, permanent visual complications. In asymptomatic cases, and when visual deficits have been prolonged enough to make recovery unlikely, flow diversion appears to be an appealing strategy towards visual preservation, though the data is not yet sufficient to inform clinical decisions. Future study is necessary to inform patient counseling due to the retrospective evidence base and low certainty of evidence.