Endovascular Treatment and Microsurgical Clipping for the Management of Paraclinoid Intracranial Aneurysms: A Systematic Review and Meta-Analysis

Objective: We aimed to compare the efficacy and safety of microsurgical clipping versus endovascular treatment (EVT) for paraclinoid aneurysms. Methods: A systematic search for studies including patients with paraclinoid aneurysms treated with a microsurgical or endovascular technique was conducted in 6 databases from inception to February 2022. Efficacy outcomes included complete angiographic occlusion at last follow-up, favorable functional outcome, and recurrence of the aneurysm. For safety, we assessed a composite of intraoperative and postoperative complications. Data were pooled using a random-effects model. Results: A total of 95 studies including 6711 patients, 3029 in the surgical group and 3682 in the EVT group were found. Pooled rates of complete occlusion were 94% (95% CI 91%–96%; I² = 0%) in the surgical group and 69% (95% CI 63%–74%; I² = 79%) in the EVT group, respectively. The favorable functional outcome rate was 86% (95% CI 76%–92%; I² = 72%) with surgical treatment and 95% (95% CI 92%–97%; I² = 61%) with EVT. The rate of aneurysm recurrence with surgical treatment was 1% (95% CI 0%–4%; I² = 0%) and 12% (95% CI 9%–16%; I² = 57%) with EVT. The composite safety outcome rate in the surgical group was 24% (95% CI 18%–30%; I² = 90%) and 10% (95% CI 8%–13%; I² = 71%) in the EVT group. Conclusions: Our findings suggest that microsurgical clipping seems to have a higher efficacy than EVT in terms of angiographic occlusion and aneurysm recurrence; however, EVT seems to be safer in terms of intraoperative and postoperative complications. Considering the heterogeneity and low-level evidence of the data available, further prospective randomized studies are warranted to confirm our findings.