Rossi Yohanna Idsabella, Bolner Gabriel, Dall'Acqua Jonathan Costa, de Oliveira Fabiana Dolovitsch, Zacaria Lucas Vincenzi, Denicol Taís Luise, Frudit Michel, Oliveira Souza Natália Vasconcellos De
Federal University of Health Sciences of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.
Intervention Neuroradiology and Neurosurgery Department, University of São Paulo, São Paulo, Brazil.
Neurosurg Rev. 2025 Aug 4;48(1):587. doi: 10.1007/s10143-025-03713-9.
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.
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.
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.
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.
老年蛛网膜下腔出血（SAH）患者面临着不成比例的高发病率和死亡率负担。虽然血管内栓塞术在此类人群中常受青睐，但与手术夹闭术的直接比较有限。我们进行了一项荟萃分析，以比较年龄≥60岁的SAH患者夹闭术与栓塞术的治疗效果。
系统检索PubMed、Embase和Cochrane数据库，以确定比较该年龄组两种治疗方法的研究。主要结局是不良结局（改良Rankin量表[mRS]＞2和死亡率）的综合指标。次要结局包括死亡率、良好结局（mRS 0-2）、再出血和住院时间。使用I²统计量评估异质性，并按年龄十年进行亚组分析。
纳入27项研究（2项随机对照试验[RCT]），涉及51415例患者（59.6%接受夹闭术治疗）。夹闭术与栓塞术在不良结局（RR 1.03；95%CI 0.96-1.11）、良好结局（RR 1.02；95%CI 0.93-1.11）、死亡率（RR 1.08；95%CI 0.97-1.19）或再出血（RR 1.21；95%CI 0.57-2.57）方面无显著差异。然而，栓塞术与较短的住院时间相关（MD -2.53天；95%CI -4.58至-0.49；p = 0.0152）。RCT显示出倾向于栓塞术的非显著趋势，而观察性研究倾向于夹闭术。主要结局的异质性为中度（I² = 57.7%）。使用GRADE框架，证据的总体确定性被评为非常低，主要是由于非随机研究占主导、偏倚风险中等以及各研究之间存在不一致性。
在年龄≥60岁的SAH患者中，夹闭术和栓塞术显示出可比的结局，栓塞术与较短的住院时间相关。鉴于证据的确定性非常低，这些发现应谨慎解释。需要前瞻性多中心队列研究来建立更确凿的证据。
