Preventive clipping versus coiling in unruptured intracranial aneurysms: A comprehensive meta-analysis and systematic review to explore safety and efficacy

Abstract

Background: Surgical clipping and endovascular coiling are both effective in preventing aneurysmal subarachnoid hemorrhage, but the choice between these interventions remains controversial, leading to treatment disparities across medical centers.

Methods: A systematic review and meta-analysis were conducted, including relevant two-arm clinical trials up to September 2023, sourced from Scopus, PubMed, Web of Science, and the Cochrane Library. Our primary outcomes were complete occlusion rates during mid-term and long-term follow-ups. Standard mean differences and risk ratios were used to analyze variations in outcomes. Python meta-analysis with sensitivity testing and regional subgroup analysis was used to resolve heterogeneity.

Results: The analysis included 139,485 participants. Clipping demonstrated significantly higher complete occlusion rates in midterm follow-up (RR = 0.83, 95% CI [0.75, 0.91], p = 0.0001) but was associated with a higher risk of procedural complications such as bleeding and ischemic stroke. Coiling showed a higher risk of retreatment (RR = 3.46, 95% CI [1.21, 9.86], p = 0.02), yet it had lower procedural complications (RR = 0.54, 95% CI [0.38, 0.78], p < 0.0009), shorter hospital stays (MD 4.36, 95% CI [2.96, 5.77], p = 0.0001), and better post-procedural outcomes as indicated by lower modified Rankin Scale scores (RR = 0.73, 95% CI [0.55, 0.97], p = 0.03). Long-term occlusion rates were comparable between the two methods.

Conclusion: While clipping achieves higher mid-term occlusion rates, coiling is associated with fewer complication rates, shorter hospital stays, and potentially better long-term outcomes. Treatment decisions should be individualized, considering patient-specific characteristics and procedural feasibility.

Keywords: Clipping; Coiling; Intracranial arterial aneurysm; Subarachnoid hemorrhage.