• Meshal Alreshidi, David J Cote, Hormuzdiyar H Dasenbrock, Michael Acosta, Anil Can, Joanne Doucette, Thomas Simjian, M Maher Hulou, Lee A Wheeler, Kevin Huang, Hasan A Zaidi, Rose Du, M Ali Aziz-Sultan, Rania A Mekary, and Timothy R Smith.
• Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts.
• Neurosurgery. 2018 Nov 1; 83 (5): 879-889.

BackgroundOpen microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo.ObjectiveTo compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis.MethodsA systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed.ResultsThirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different.ConclusionThis updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

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