title: Clinical outcome after surgical clipping or endovascular coiling for cerebral aneurysms: a pragmatic meta-analysis of randomized and non-randomized trials with short- and long-term follow-up.
abstract: BACKGROUND
  Two randomized trials have evaluated clipping and coiling in patients with ruptured aneurysms. Aggregated evidence for management of ruptured and unruptured aneurysms is missing.
  
  
  OBJECTIVE
  To conduct a meta-analysis evaluating clinical outcome after aneurysm treatment.
  
  
  METHODS
  PubMed, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov were searched for studies evaluating aneurysm treatment. The primary outcome measure was an independent clinical outcome (modified Rankin scale 0-2, Glasgow Outcome Scale 4-5, or equivalent). Secondary outcomes were poor outcome and mortality. ORs were calculated on an intention-to-treat basis with 95% CIs. Outcome heterogeneity was evaluated with Cochrane's Q test (significance level cut-off value at <0.10) and I2(significance cut-off value >50%) with the Mantel-Haenszel method for dichotomous outcomes. A p value <0.05 was regarded as statistically significant.
  
  
  RESULTS
  Searches yielded 18 802 articles. All titles were assessed, 403 abstracts were evaluated, and 183 full-text articles were read. One-hundred and fifty articles were qualitatively assessed and 85 articles were included in the meta-analysis. Patients treated with coiling (randomized controlled trials (RCTs)) had higher independent outcome at short-term follow-up (OR=0.67, 95% CI 0.57 to 0.79). Independent outcome was favored for coiling at intermediate and long-term follow-up (RCTs and observational studies combined-OR=0.80, 0.68 to 0.94 and OR=0.81, 0.71 to 0.93, respectively). Independent outcome and lower mortality was favored after coiling in unruptured aneurysms (database registry studies) at short-term follow-up (OR=0.34, 0.29 to 0.41 and OR=1.74, 1.52 to 1.98, respectively).
  
  
  CONCLUSIONS
  This meta-analysis evaluating clinical outcome after coiling or clipping for intracranial aneurysms, indicates a higher independent outcome and lower mortality after coiling.
authors.affiliation: Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
authors.forename: Alberto
authors.initials: A
authors.lastname: Falk Delgado
authors.affiliation: Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.|Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.|Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium.
authors.forename: Tommy
authors.initials: T
authors.lastname: Andersson
authors.affiliation: Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.|Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Anna
authors.initials: A
authors.lastname: Falk Delgado
mesh_terms: D017542:Aneurysm, Ruptured / Q000175:diagnosis / Q000601:surgery; D016208:Databases, Factual / Q000639:trends; D019468:Disease Management; D004621:Embolization, Therapeutic / Q000295:instrumentation / Q000379:methods; D057510:Endovascular Procedures / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D064887:Observational Studies as Topic / Q000295:instrumentation / Q000379:methods*; D016032:Randomized Controlled Trials as Topic / Q000295:instrumentation / Q000379:methods*; D013525:Surgical Instruments; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aneurysm; Coil; Hemorrhage; Intervention