Endovascular Therapy Versus Surgical Clipping for Intracranial Aneurysms: A Systematic Review and Meta-Analysis

Abstract

Intracranial aneurysms are a leading cause of subarachnoid hemorrhage (SAH), associated with high morbidity and mortality. Traditionally, microsurgical clipping was the gold standard, but endovascular coiling has emerged as a less invasive alternative. This review synthesizes current evidence comparing endovascular and surgical approaches. A systematic search was conducted across PubMed, Scopus, and the Cochrane Library, including randomized controlled trials (RCTs) and cohort studies published between 2000 and 2025. Outcomes assessed were mortality, functional independence, perioperative complications, recurrence, and retreatment rates. Twenty-seven studies encompassing 18,560 patients were analyzed. Endovascular therapy demonstrated reduced short-term mortality and higher rates of functional independence, particularly in elderly patients and those with posterior circulation aneurysms. Conversely, surgical clipping ensured greater long-term durability with fewer retreatments, especially among younger patients. Both techniques carry unique benefits and limitations; thus, treatment should be individualized, taking into account aneurysm morphology, patient age, comorbidities, and surgical risk. Risk of bias assessment was performed using Cochrane RoB2 for RCTs and the Newcastle-Ottawa Scale for observational studies, with most studies showing moderate risk. This review highlights the importance of a multidisciplinary, patient-centered approach, while emphasizing the need for future long-term RCTs and device innovations. In conclusion, endovascular therapy provides superior early safety, while surgical clipping ensures durable occlusion; an evidence-based, personalized strategy remains essential to optimize patient outcomes