Comparing surgical clipping with endovascular treatment for unruptured middle cerebral artery aneurysms: a systematic review and updated meta-analysis.

Autor:	Ferreira MY; 1Faculty of Medicine, Ninth July University, São Paulo, Brazil.; 10Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, New York., Batista S; 2Faculty of Medicine, Federal University of Rio de Janeiro, Brazil., Oliveira LB; 3School of Medicine, State University of Ponta Grossa, Paraná, Brazil., Marques GN; 2Faculty of Medicine, Federal University of Rio de Janeiro, Brazil., Maia HG; 4Faculty of Medicine, Estacio de Sá Cittá University (IDOMED), Rio de Janeiro, Brazil., Palavani LB; 5Max Planck University Center, Indaiatuba, São Paulo, Brazil., Andreão FF; 2Faculty of Medicine, Federal University of Rio de Janeiro, Brazil., Borges PGLB; 6School of Medicine, Technical Educational Foundation Souza Marques, Rio de Janeiro, Brazil., Semione G; 7University of West of Santa Catarina, Brazil., Sousa MP; 2Faculty of Medicine, Federal University of Rio de Janeiro, Brazil., Besborodco RM; 8Rusk Rehabilitation, NYU Langone Health, New York, New York., Bertani R; 9University of São Paulo, Department of Neurosurgery, São Paulo, Brazil; and., Serulle Y; 10Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, New York., Ferreira C; 10Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, New York., Langer D; 10Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, New York.
Jazyk:	angličtina
Zdroj:	Journal of neurosurgery [J Neurosurg] 2024 Aug 02, pp. 1-11. Date of Electronic Publication: 2024 Aug 02.
DOI:	10.3171/2024.4.JNS24343
Abstrakt:	Objective: Unruptured middle cerebral artery aneurysm (uMCAA) has traditionally been treated with open surgical clipping (SC). Endovascular treatments (EVTs) were designed to reduce surgical risks in these cases. Nevertheless, despite its potential benefits, many surgeons favor SC for uMCAA. This updated meta-analysis aimed to compare the safety, efficacy, and clinical outcomes of SC and EVT for uMCAA. Methods: The authors searched the Medline, Embase, and Cochrane Library databases according to the Cochrane and PRISMA guidelines. Eligible studies included those with ≥ 4 patients with uMCAA reporting comparative data of SC and EVT. The endpoints were the complete occlusion rate (Raymond class I and II), good clinical outcomes (modified Rankin Scale score ≤ 2 or Glasgow Outcome Scale score ≥ 4), procedure-related complications (further divided into major and minor), and mortality. The authors pooled OR with 95% CI values with a random-effects model. I2 statistics were used to assess heterogeneity, and sensitivity analysis was conducted to address high heterogeneity. Publication bias was assessed with funnel plot analysis and the Egger's test. Results: The analysis included data from 10 studies. Regarding the complete occlusion assessment, the comparative analysis revealed OR 0.17 (95% CI 0.08-0.40, p < 0.01), favoring SC. In terms of achieving good clinical outcomes, OR 0.44 (95% CI 0.20-0.97, p < 0.05) was determined, favoring SC. No differences regarding total procedure-related complications, major complications, or mortality were identified. However, a higher likelihood of minor complications was identified for EVT, with OR 4.68 (95% CI 2.01-10.92, p < 0.01). Conclusions: This systematic review and meta-analysis identified a lower likelihood of complete occlusion at last follow-up and lower likelihood of good clinical outcomes in patients treated with EVT when compared with SC. Furthermore, a higher likelihood of minor complications was identified in patients who underwent EVT when compared with SC. The findings reinforce that, based on the currently available data, SC should be considered the primary approach for treating uMCAA. However, EVT is an evolving approach, and this study's findings represent a synthesis of observational studies. Randomized trials are warranted to elucidate which approach should be the mainstay for uMCAA and to identify the nuances that determine whether SC or EVT is more or less indicated for addressing uMCAA with consideration of the individuality of each patient and aneurysm.
Databáze:	MEDLINE
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