Clipping Versus Coiling in the Management of Posterior Communicating Artery Aneurysms with Third Nerve Palsy: A Systematic Review and Meta-Analysis

World Neurosurg. 2016 Mar:87:498-506.e4. doi: 10.1016/j.wneu.2015.09.026. Epub 2015 Sep 25.


Objective: To compare surgical clipping with endovascular coiling in terms of recovery from oculomotor nerve palsy (ONP) in the management of posterior communicating artery (PCoA) aneurysms causing third nerve palsy.

Methods: We conducted a systematic review of the literature and meta-analysis.

Results: The meta-analysis included 11 relevant studies involving 384 patients with third nerve palsy caused by PCoA aneurysms at baseline, of whom 257 (67.0%) were treated by clipping and 127 were treated by coiling (33.0%). Pooled odds ratios of the impact of clipping or coiling on complete ONP recovery, lack of ONP recovery, and procedure-related death were calculated. The overall complete ONP recovery rate was 42.5% in the coiling group compared with 83.6% in the clipping group. The increase in complete ONP recovery in the clipping group corresponds to an overall pooled Mantel-Haenszel odds ratio of 4.44 (95% confidence interval = 1.66-11.84). Subgroup analysis revealed a clear benefit of clipping over coiling in patients with ruptured aneurysms, but not in patients with unruptured aneurysms. No procedure-related deaths were reported by any of the 11 studies.

Conclusions: Surgical clipping of PCoA aneurysms causing third nerve palsy achieves better ONP recovery than endovascular coiling; this could be particularly true in the case of ruptured aneurysms. In view of the purely observational data, statements about this effect should be made with great caution. A randomized trial would better address the therapeutic dilemma, but pending the results of such a trial, we recommend treating PCoA aneurysms causing ONP with surgery.

Keywords: Endovascular procedure; Intracranial aneurysm; Meta-analysis; Microsurgery; Oculomotor nerve diseases.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Cerebral Arteries / surgery
  • Humans
  • Intracranial Aneurysm / complications*
  • Intracranial Aneurysm / surgery*
  • Neurosurgical Procedures / methods*
  • Oculomotor Nerve*
  • Ophthalmoplegia / etiology*
  • Surgical Instruments