Surgery or Endovascular Treatment in Patients with Anterior Communicating Artery Aneurysm: A Systematic Review and Meta-analysis

Introduction: Although randomized controlled trials have compared surgery versus endovascular treatment for intracranial aneurysms, the literature is sparse in terms of subgroup analysis for anterior communicating artery (ACoA) aneurysm management. This systematic review and meta-analysis seeks to reach a consensus in this regard.

Methods: Medline, PubMed, and Embase were searched from inception to November 16th, 2021. Primary outcomes were post-treatment modified Rankin Scale (mRS) >2 and mortality. Secondary outcomes were aneurysm obliteration, retreatment, and recurrence.

Results: Fifteen studies yielding 1926 patients were included, of which 973 (50.5%) underwent surgery and 953 (49.4%) underwent endovascular treatment. The odds ratio (OR) of mortality (OR=0.88[0.57-1.34], p=0.54) and mRS>2 (OR=0.75[0.50-1.13], p=0.17) were similar between the two groups. In the surgery group, the OR of obliteration (OR=2.2[1.17-4.12], p=0.01) was higher, while the OR of retreatment (OR=0.37[0.17-0.81], p=0.01) and recurrence (OR=0.22[0.10-0.47], p=0.0001) were lower relative to the endovascular group. The level of evidence was moderate to high per the GRADE approach.

Conclusion : ACoA aneurysms may be safely treated with either surgery or endovascular treatment, although microsurgical clipping demonstrates higher obliteration rates and lower rates of retreatment and recurrence.