Clipping Versus Coiling in Ruptured Middle Cerebral Artery Aneurysms: A Comparative Meta-Analysis Of Head-To-Head Studies

Background: The optimal treatment strategy for ruptured middle cerebral artery (MCA) aneurysms remains debated, with microsurgical clipping offering superior occlusion rates and endovascular coiling being less invasive. While ISAT demonstrated improved 12-month clinical outcomes, such as risk of rebleeding with coiling, MCA aneurysms were underrepresented. Coiling also had higher recurrence and retreatment rates compared to clipping. This meta-analysis provides a comparative assessment of clinical and radiographic outcomes between clipping and coiling in ruptured MCA aneurysms. Methods: A PRISMA-compliant systematic review and meta-analysis was conducted using MEDLINE and EMBASE through February 2024. Studies reporting occlusion rates, clinical outcomes, and complications for both clipping and coiling in ruptured MCA aneurysms were included. Statistical analysis was performed using a random-effects model with risk ratios (RR) and odds ratios (OR) reported with 95% confidence intervals (CI). Heterogeneity was assessed via Cochran’s Q test and I 2 statistic. Results: A total of twelve studies (614 patients: 388 clipping, 226 coiling) met inclusion criteria. Clipping was associated with significantly higher rates of complete occlusion (Raymond-Roy grade I) (RR = 1.45, 95% CI: 1.25–1.68, p < 0.0001) while coiling had a higher rate of Raymond-Roy grade II occlusion (RR = 0.29, 95% CI: 0.19–0.44, p < 0.0001). Retreatment rates were significantly lower following clipping (OR = 0.41, 95% CI: 0.15–1.13, p = 0.08). No significant differences were found in intraoperative rupture, Raymond-Roy grade III rate, mRS 0-2 at discharge or 12 months, rebleeding, postoperative stroke, vasospasm, secondary decompressive craniectomy, shunt-dependent hydrocephalus, or mortality. Conclusion: Microsurgical clipping achieves significantly higher complete occlusion rates and lower retreatment rates compared to coiling in ruptured MCA aneurysms. Clinical outcomes, complication rate, mortality, or Raymond-Roy grade III occlusion was not significantly different between treatment modalities. Given evolving endovascular techniques and inherent selection bias, further propensity-matched studies are warranted to refine treatment guidelines and optimize patient outcomes. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany