Objective: Microsurgery for cerebral aneurysms is called definitive, yet some patients undergo a craniotomy that results in noncurative treatment. Furthermore, the overall rate of noncurative microsurgery for cerebral aneurysms is unclear. The objective of this study was to complete a systematic review and meta-analysis to quantify three scenarios of noncurative treatment: aneurysm wrapping, postclipping remnants, and late regrowth of completely obliterated aneurysms.
Methods: A PRISMA-guided systematic literature review of the MEDLINE and Cochrane Library databases and meta-analysis was completed. Studies were included that detailed rates of aneurysm wrapping, residua confirmed with imaging, and regrowth after confirmed total occlusion. Pooled rates were subsequently calculated using a random-effects model. An assessment of statistical heterogeneity and publication bias among the included studies was also completed for each analysis, with resultant I2 values and p values determined with Egger's test.
Results: Sixty-four studies met the inclusion criteria for final analysis. In 41 studies, 573/15,715 aneurysms were wrapped, for a rate of 3.5% (95% CI 2.7%-4.2%, I2 = 88%). In 43 studies, 906/13,902 aneurysms had residual neck or dome filling, for a rate of 6.4% (95% CI 5.2%-7.6%, I2 = 93%). In 15 studies, 71/2568 originally fully occluded aneurysms showed regrowth, for a rate of 2.1% (95% CI 1.2%-3.1%, I2 = 58%). Together, there was a total rate of noncurative surgery of 12.0% (95% CI 11.5%-12.5%). Egger's test suggested no significant publication bias among the studies. Meta-regression analysis revealed that the reported rate of aneurysm wrapping has significantly declined over time, whereas the rates of aneurysm residua and recurrence have not significantly changed.
Conclusions: Open microsurgery for cerebral aneurysm results in noncurative treatment approximately 12% of the time. This metric may be used to counsel patients and as a benchmark for other treatment modalities. This investigation is limited by the high degree of heterogeneity among the included studies.
Keywords: cerebral aneurysms; microsurgery; subarachnoid hemorrhage; surgical clipping; vascular disorders.