Comparative outcomes of coil embolization and surgical clipping in elderly patients with subarachnoid hemorrhage: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES

Elderly patients with subarachnoid hemorrhage (SAH) face a disproportionately high burden of morbidity and mortality. While endovascular coiling is often favored in this population, direct comparisons with surgical clipping are limited. We conducted a meta-analysis to compare outcomes of clipping versus coiling in SAH patients aged ≥ 60 years.

METHODS

A systematic search of PubMed, Embase, and Cochrane databases identified studies comparing the two treatments in this age group. The primary outcome was a composite of unfavorable outcomes (modified Rankin Scale [mRS] > 2 and mortality). Secondary outcomes included mortality, favorable outcome (mRS 0-2), rebleeding, and hospital length of stay. Heterogeneity was assessed using I² statistics, with subgroup analysis by age decade.

RESULTS

Twenty-seven studies (2 randomized controlled trials [RCTs]) involving 51,415 patients (59.6% treated with clipping) were included. There were no significant differences between clipping and coiling for unfavorable outcome (RR 1.03; 95% CI 0.96-1.11), favorable outcome (RR 1.02; 95% CI 0.93-1.11), mortality (RR 1.08; 95% CI 0.97-1.19), or rebleeding (RR 1.21; 95% CI 0.57-2.57). However, coiling was associated with shorter hospital stays (MD -2.53 days; 95% CI -4.58 to -0.49; p = 0.0152). RCTs showed a non-significant trend favoring coiling, while observational studies leaned toward clipping. Heterogeneity for main outcomes was moderate (I² = 57.7%). Using the GRADE framework, overall certainty of evidence was rated very low, mainly due to the predominance of non-randomized studies, moderate risk of bias, and inconsistency across studies.

CONCLUSIONS

In SAH patients aged ≥ 60 years, clipping and coiling show comparable outcomes, with coiling associated with shorter hospital stays. Given the very low certainty of evidence, these findings should be interpreted with caution. Prospective multicenter cohorts are needed to establish more definitive evidence.