Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru.
Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru; Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru; Abdulrauf University of Neurosurgery, Simi Valley, California, USA.
World Neurosurg. 2023 Oct;178:e489-e509. doi: 10.1016/j.wneu.2023.07.108. Epub 2023 Jul 28.
We aimed to compare the efficacy and safety of microsurgical clipping versus endovascular treatment (EVT) for paraclinoid aneurysms.
A systematic search for studies including patients with paraclinoid aneurysms treated with a microsurgical or endovascular technique was conducted in 6 databases from inception to February 2022. Efficacy outcomes included complete angiographic occlusion at last follow-up, favorable functional outcome, and recurrence of the aneurysm. For safety, we assessed a composite of intraoperative and postoperative complications. Data were pooled using a random-effects model.
A total of 95 studies including 6711 patients, 3029 in the surgical group and 3682 in the EVT group were found. Pooled rates of complete occlusion were 94% (95% CI 91%-96%; I = 0%) in the surgical group and 69% (95% CI 63%-74%; I = 79%) in the EVT group, respectively. The favorable functional outcome rate was 86% (95% CI 76%-92%; I = 72%) with surgical treatment and 95% (95% CI 92%-97%; I = 61%) with EVT. The rate of aneurysm recurrence with surgical treatment was 1% (95% CI 0%-4%; I = 0%) and 12% (95% CI 9%-16%; I = 57%) with EVT. The composite safety outcome rate in the surgical group was 24% (95% CI 18%-30%; I = 90%) and 10% (95% CI 8%-13%; I = 71%) in the EVT group.
Our findings suggest that microsurgical clipping seems to have a higher efficacy than EVT in terms of angiographic occlusion and aneurysm recurrence; however, EVT seems to be safer in terms of intraoperative and postoperative complications. Considering the heterogeneity and low-level evidence of the data available, further prospective randomized studies are warranted to confirm our findings.
比较显微夹闭与血管内治疗（EVT）治疗颅底旁动脉瘤的疗效和安全性。
系统检索了从建库到 2022 年 2 月期间，采用显微或血管内技术治疗颅底旁动脉瘤的患者的研究。疗效结果包括末次随访时完全血管造影闭塞、良好的功能结局和动脉瘤复发。安全性方面，我们评估了术中及术后并发症的综合情况。使用随机效应模型对数据进行合并。
共纳入 95 项研究，包括 6711 例患者，其中手术组 3029 例，EVT 组 3682 例。手术组完全闭塞率为 94%（95% CI 91%-96%；I²=0%），EVT 组为 69%（95% CI 63%-74%；I²=79%）。手术治疗的良好功能结局率为 86%（95% CI 76%-92%；I²=72%），EVT 组为 95%（95% CI 92%-97%；I²=61%）。手术治疗的动脉瘤复发率为 1%（95% CI 0%-4%；I²=0%），EVT 组为 12%（95% CI 9%-16%；I²=57%）。手术组的复合安全性结局发生率为 24%（95% CI 18%-30%；I²=90%），EVT 组为 10%（95% CI 8%-13%；I²=71%）。
我们的研究结果表明，在血管造影闭塞和动脉瘤复发方面，显微夹闭的疗效似乎优于 EVT；然而，在术中及术后并发症方面，EVT 似乎更安全。鉴于现有数据的异质性和低水平证据，需要进一步的前瞻性随机研究来证实我们的研究结果。
