Presentation, management and outcomes of ruptured intracranial aneurysms in Africa: A systematic review and meta-analysis

Background: Approximately two percent of the world's population are affected by intracranial aneurysms (IAs). This study aimed to evaluate literature regarding presentation, treatment and outcomes of ruptured IAs in Africa. Methods: A systematic review of the literature using PubMed/MEDLINE, SCOPUS, Web of Science and Google Scholar databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines. Results: Twenty-one retrospective studies with 1,109 patients and 11 case reports (10 countries) were included. The mean Methodological Index for Nonrandomized Studies (MINORS) for included articles was 9.1 +/- 2.5. The mean age was 43.3 years (95 %CI: 37.8-48.8), with 58.4 % (342/586) female patients. WFNS/H&H grade 1 was reported in 41.2 % (98/238) of cases and Fischer grade 2 was reported in 30.4 % (98/322) of cases. CT angiography was utilized in 94.6 % (560/592, 12 articles). The ICA was reported in 24.5 % of cases (CI: 12.9 %-36.1 %). AComA and MCA were affected in 21.2 % (95 %CI: 15.2-27.2 %) and 21.3 % (95 %CI: 15.2-27.2 %) of cases, respectively. The odds of ruptured aneurysms in the anterior circulation were 14.3 (CI: 6.3-32.2). Surgical clipping was reported in 75.0 % (448/597) and coiling in 20.4 % (122/597) across 13 studies. 66.8 % (95 %CI: 57.4-76.3 %) of patients experienced neurological improvement with a mortality rate of 12.3 % (95 %CI: 7.5-17.1 %) at last follow-up. Conclusion: Ruptured IAs are small and located in the anterior circulation. The lack of detailed aneurysm size reporting hampers the identification of a critical rupture size for management. More research is needed to understand aneurysm characteristics and predictors of rupture in Africa.