Abstract / Summary
Aneurysmal subarachnoid hemorrhage (aSAH) carries high morbidity and mortality despite advances in aneurysm repair. Microsurgical clipping and endovascular coiling are established treatment modalities, yet their relative benefits regarding functional outcome and long-term aneurysm occlusion remain debated. This study evaluates treatment effects stratified by aneurysm location and clinical grade.
We identified RCTs comparing clipping and coiling for ruptured intracranial aneurysms. Primary outcomes were favorable functional outcome at 1-year [modified Rankin Scale (mRS), and complete aneurysm occlusion at 1-year]. Secondary outcomes included location-specific analyses, WFNS grade-specific analyses, and all-cause mortality.
Six RCTs involving up to 3044 patients were included. Coiling was associated with higher odds of favorable outcome at 1 year using mRS 0-2 (OR 1.60, 95% CI 1.36-1.88; p < 0.00001), but not when using mRS 0-3 (OR 1.19, p = 0.12). Location-specific analyses showed better outcomes after coiling for internal carotid artery aneurysms (OR 0.44, p < 0.00001), no difference for anterior communicating, anterior cerebral, middle cerebral, or posterior circulation aneurysms. Complete occlusion at 12 months favored clipping overall (OR 0.35, 95% CI 0.28-0.44; p < 0.00001; I2 = 0%), driven by superiority in middle cerebral artery aneurysms (OR 5.21, p = 0.007). Mortality did not differ (OR 0.89, p = 0.35).
Coiling offers superior 1-year functional outcomes when assessed with mRS 0-2, while clipping achieves higher complete occlusion rates, predominantly in middle cerebral artery aneurysms. No mortality difference was found.