Effectivity and safety of endovascular coiling versus microsurgical clipping for aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis

Background: There is an ongoing lack of consensus among clinicians regarding on the optimal aneurysmal subarachnoid hemorrhage (aSAH) management approach between endovascular coiling and microsurgical clipping.Methods: Comprehensive literature search for randomized controlled trials (RCTs) was conducted in Medline and Cochrane databases until January 1st, 2023 without language constraints. Effectivity outcomes included one year mortality, one-year poor outcomes, and one-year complete aneurysmal occlusion, while safety outcomes comprised the incidence of vasospasms, rebleeding, post-operative complications, and cerebral ischemia.Results: Eight RCTs, involving 3585 aSAH patients, underwent comprehensive quantitative analysis. Among them, 1792 underwent endovascular coiling and 1773 patients had microsurgical clipping. Regarding effectivity, the rates of one-year mortality (OR: 0.79, 95% CI: 0.61-1.03, p = 0.08) exhibited no significant difference. However, endovascular coiling demonstrated an inferior one-year complete aneurysmal occlusion rate (OR: 0.33, 95% CI: 0.21-0.53, p < 0.00001), although with significantly lower rates of poor outcomes (OR: 0.68, 95% CI: 0.57-0.81, p < 0.00001) compared to the microsurgical clipping group. As for safety, endovascular coiling group exhibited lower rates of vasospasm (OR: 0.58, 95% CI: 0.36-0.92, p = 0.02), post-operative complications (OR: 0.40, 95% CI: 0.23-0.71, p = 0.02), and cerebral ischemia (OR: 0.36, 95% CI: 0.20-0.63, p = 0.0004). No significant effect on the incidence of rebleeding was observed (OR: 1.09, 95% CI: 0.73-1.63, p = 0.68).Conclusions: Endovascular coiling proves superior and safer for aSAH patients, but consideration of resources, patient condition, and surgeon preferences is crucial for selecting the optimal approach.