Role of Intracranial Aneurysm Location in Determining Optimal Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

This meta-analysis aims to evaluate the influence of aneurysm location on optimal management strategies, specifically comparing clipping and coiling. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) collected from PubMed, Scopus, and Google Scholar up to December 2024. The mixed-effects model reported a dichotomous outcome using the risk ratio (RR) with a 95% confidence interval (CI). Subgroup analysis was performed, and statistical heterogeneity was evaluated using I² statistics. Bias was assessed using funnel plots and Egger's test. The primary outcome included the mortality rate among clipping and coiling treatments, and the secondary endpoint was a favorable functional outcome at 1-5 years of follow-up. We included eight RCTs, totaling 8199 patients, and the qualitative systematic review analysis showed that most aneurysms are located in the anterior circulation, with a predominantly female distribution. Clipping has been beneficial for middle cerebral artery (MCA) and anterior communicating artery (AComA) aneurysms. Meanwhile, coiling for the posterior circulation carries a higher risk of rupture and rebleeding. In quantitative meta-analysis, coiling showed a significant reduction of mortality as compared to clipping, with a pooled RR (RR = 0.84; 95% CI: 0.75-0.95; P = 0.05; I² = 48%). Favorable functional outcome was seen as more significant in coiling than clipping (RR = 0.9; 95% CI: 0.80-1.01; I² = 25.7%; τ² = 0.0052; P = 0.224) using the random-effects model. The subgroup analysis for AComA aneurysms indicated that coiling seemed to lead to safer results (RR = 0.88; 95% CI: 0.75-1.04), while for MCA aneurysms, clipping appeared to be better (RR = 1.72; 95% CI: 0.78-3.77). In the case of internal carotid artery (ICA) aneurysm, coiling has been associated significantly with a lower rate of mortality and dependency (RR = 0.60; 95% CI: 0.49-0.75), and the posterior circulation did not reveal any association of outcome with either treatment (RR = 0.97; 95% CI: 0.11-8.86). The evidence suggests that coiling has been beneficial in terms of overall mortality reduction and better functional outcomes. However, clipping has shown effectiveness for MCA aneurysms, and coiling has proven to be a slightly safer modality for AComA and a significantly preferable modality for ICA aneurysms. No significant association of outcome was found among the posterior circulation, clipping, or coiling.