Neurosurgical Clipping versus Endovascular Coiling for Patients with Intracranial Aneurysms: A Systematic Review and Meta -Analysis

Objective: We compared the efficacy and safety of neurosurgical clipping with those of endovascular coiling for patients with intracranial aneurysm (IA) stratified by country, publication year, study design, sample size, mean age, percentage of male patients, percentage of aneurysms located in the anterior circulation, and follow-up duration. Methods: We identified 64 studies (7 randomized controlled trials, 21 prospective cohort studies, and 36 retrospective studies) of clipping versus coiling for IA from PubMed, EmBase, and the Cochrane Library up to September 2019. Results: No significant differences were found in the incidence of poor outcomes observed between clipping and coiling for patients with ruptured IAs. In contrast, the incidence of a poor outcome was significantly increased for unruptured IAs treated by clipping. Clipping was associated with a lower risk of mortality for ruptured IAs, although no significant differences were found between clipping and coiling for unruptured IAs. Clipping was associated with a lower risk of rebleeding for ruptured IAs and an increased risk of bleeding for unruptured IAs. When only randomized controlled trials were included in the analysis, patients with ruptured IAs treated by clipping had an increased incidence of poor outcomes compared with those treated by coiling. Clipping reduced the risk of hydrocephalus and incomplete occlusion and increased the rate of complete occlusion for ruptured IAs. No significant differences in the risk of ischemic infarct and vasospasm were found between clipping and coiling. Conclusions: Surgical clipping might be superior to endovascular coiling for ruptured IAs. However, clipping was associated with a greater incidence of poor outcomes and bleeding compared with coiling for unruptured IAs. © 2020 Elsevier Inc.