Microsurgical clipping versus Woven EndoBridge embolization for intracranial aneurysms: a systematic review and...

To compare microsurgical clipping and Woven EndoBridge (WEB) embolization for the treatment of intracranial aneurysms, including ruptured and unruptured cases, with respect to angiographic occlusion, morbidity, mortality, and adverse events (AEs). This systematic review and meta-analysis followed PRISMA guidelines and the Cochrane Handbook. PubMed, Scopus, and Web of Science were searched from inception to January 29, 2026, for comparative studies evaluating microsurgical clipping versus WEB embolization. Cohort studies and clinical trials were eligible regardless of aneurysm rupture status or morphology. Study selection and data extraction were performed independently by two reviewers. Risk of bias was assessed using the Newcastle-Ottawa Scale. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was assessed with the I² statistic, and predefined subgroup and sensitivity analyses were conducted. Five observational cohort studies comprising 798 patients (402 clipping, 396 WEB) were included. The most credible estimate, from the good-quality concurrent studies, showed higher occlusion with clipping (RR 1.30, 95% CI 1.14 to 1.49, I² 0%). Larger pooled estimates (RR 1.71 for complete occlusion; RR 2.04 in the two-study wide-neck analysis) were strongly influenced by fair-quality studies that used external WEB comparators and by near-ceiling clipping occlusion combined with small WEB denominators, and are presented as exploratory. Adequate or complete occlusion also favored clipping (RR: 1.61, 95% CI: 1.24-2.11; P = 0.0004). There were no significant differences in morbidity (RR: 0.86, 95% CI: 0.33-2.25) or overall mortality (RR: 0.69, 95% CI: 0.37-1.28). Reported adverse-event frequencies appeared broadly comparable, although inconsistent reporting across studies precluded formal comparative analysis, and the profile of complications differed between techniques. Across wide-neck aneurysms and within the available short-term follow-up, microsurgical clipping was consistently associated with higher angiographic occlusion than WEB embolization, which was the more internally consistent estimate, although heterogeneity increased when all wide-neck-only studies were combined. No statistically significant difference was observed in morbidity or mortality. Because WEB occlusion may progress over time and long-term retreatment and recurrence data are limited, these short-term angiographic findings should not be interpreted as evidence of superior long-term durability. Because all included studies were observational, these comparisons are susceptible to selection bias, and treatment selection should remain individualized according to aneurysm characteristics, rupture status, and clinical context.