Abstract Body: Introduction: Ruptured posterior circulation aneurysms (PCAs) represent a unique subset of subarachnoid hemorrhage with higher morbidity and mortality due to complex vascular anatomy and limited surgical accessibility. Despite advances in microsurgical and endovascular techniques, the optimal treatment remains debated. This meta-analysis compares clinical and radiologic outcomes between microsurgical clipping and endovascular coiling in patients with ruptured PCAs.
Methods: A systematic search of PubMed, Embase, and the Cochrane Library was conducted from database inception through May 2025 following PRISMA 2020 guidelines. Randomized and observational studies directly comparing clipping and coiling in ruptured PCAs were included. Primary outcomes were functional outcomes [reported by Glasgow Outcome Scale (GOS) or modified Rankin Scale (mRS)] and mortality. Secondary outcomes included aneurysm-related events, procedural complications, and healthcare utilization measures such as retreatment, ischemic events, vasospasm, and hospital stay. Pooled effect estimates were calculated using a random-effects model, and heterogeneity was assessed using the I2 statistic. Study quality was evaluated using the Cochrane Risk of Bias 2 (RoB 2) and Newcastle–Ottawa Scale tools.
Results: Fifteen studies comprising 7,721 patients (4,194 clipping; 3,528 coiling) were included. Baseline characteristics were similar. Good functional outcome at discharge was similar between groups (RR 0.93; 95% CI 0.75–1.17; p = 0.55), while coiling showed a modest advantage at 6 months (RR 0.86; 95% CI 0.76–0.98; p = 0.02). Mortality did not differ significantly (RR 0.95; 95% CI 0.85–1.07; p = 0.40). Clipping had higher cerebral infarction rates (RR 1.56; 95% CI 1.03–2.38; p = 0.04) but lower postoperative vasospasm (RR 0.59; 95% CI 0.38–0.90; p = 0.01). Heterogeneity was moderate to high across outcomes.
Conclusion: Overall, coiling provided comparable or superior early functional outcomes with fewer ischemic complications, whereas clipping offered greater procedural durability through lower retreatment rates. These findings support individualized anatomy-based decision-making to optimize outcomes in this high-risk neurosurgical population.