Introduction/purpose Neuroendovascular therapies are increasingly used in treatment of cerebral aneurysms. However, data is sparse on outcomes of various treatment strategies for anterior cerebral artery (ACA) territory. We performed a systematic review and meta-analysis to compare outcomes of treatment strategies for ruptured or unruptured ACA aneurysms from prior high quality published data.
Materials and methods We searched MEDLINE, Embase, and Cochrane from January 2000 until January 2018. High quality studies were included that had reported initial morbidity indices, occlusion rates, late follow up data, and operative complications (ischemic, hemorrhagic, retreatment rate) for endovascular coiling vs pipeline flow-diversion vs neurosurgical clipping separately reported for ruptured and unruptured aneurysms of ACA territory. Random-effect or fixed-effect models were used to pool estimates across studies using R software.
Results Overall, 1230 ACA aneurysms from 22 studies including 910 (775 ruptured) coiling, 105 pipeline (All unruptured) and 140 clipping (130 ruptured) treatments were identified using a systematic method. For ruptured ACA aneurysms treated with coiling, occlusion rates were 0.86 (0.84–0.89) and 0.85 (0.72–0.93) in immediate and late assessment respectively. Final occlusion rate was 0.96 (0.87–0.99) for ruptured ACA aneurysms treated with clipping. For unruptured ACA aneurysms treated with coiling, occlusion rates were 0.93 (0.85–0.97) and 0.86 (0.73–0.93) in immediate and late assessment respectively. Final occlusion rate was 0.82 (0.71–0.89) for unruptured ACA aneurysms treated with pipeline device. For ruptured ACA aneurysms treated with coiling, secondary ICH occurred in 0.08 (0.07–0.11) (n=731) and retreatment rate was 0.10 (0.05–0.18). For those treated with clipping, ICH occurred in 0.12 (0.03–0.37) and retreatment rate was 0.06 (0.02–0.13) (n=110). No study of ruptured ACA aneurysm treated with pipeline device was eligible to be included in our meta-analysis. For unruptured ACA aneurysms treated with coiling, the risk of ischemic stroke was 0.09 (0.05–0.18) (n=121), ICH occurred in 0.05 (0.02–0.12) (n=121) and retreatment rate was 0.10 (0.05–0.18) (n=100). For those treated with pipeline device, the risk of ischemic stroke was 0.03 (0.01–0.09) (n=103), ICH occurred in 0.04 (0.02–0.11) and retreatment rate was 0.02 (0.01–0.08) (n=105). Meta-analysis was not technically possible for unruptured ACA aneurysm treated with surgical clipping due to small numbers.
Conclusion Endovascular and surgical treatment modalities appear safe and effective in treatment of ACA aneurysm. There is a large amount of heterogeneity in reporting baseline characteristics and final outcomes in the literature limiting number of studies for comparison of outcomes by vascular territory.
Disclosures H. Saber: None. G. Rajah: None. H. Fadel: None. B. Kolb: None. A. Luqman: None. S. Narayanan: None.
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