Antiplatelet therapy in aneurysmal subarachnoid hemorrhage: an updated meta-analysis

Exclusion criteria in randomized clinical trials of subarachnoid hemorrhage

INTRODUCTION

Exclusion criteria are designed to optimize the scientific yield and safety of clinical trials. However, periodic analysis is necessary to understand the impact on trial complexity, enrollment, generalizability, and costs. We analyzed the types of exclusion criteria used among clinical trials performed in subarachnoid hemorrhage (SAH) patients and impact upon exclusion of patients.

METHODS

We identified trials involving SAH patients that provided a list of exclusion criteria and determined the number and proportion of those trials which used various exclusion criteria, proportion of excluded patients for each of the exclusion criteria and whether Consolidated Standards of Reporting Trials (CONSORT) was used. We also used target trial emulation approach and applied arbitrary trial exclusion criteria to a single center cohort of SAH patients to determine proportions of patients excluded for each of the reasons for exclusion.

RESULTS

A total of 109 trials involving SAH patients were identified, of which 68(62.3%) provided a list of the exclusion criteria. The median number of exclusion criteria was 6 (range 2-9). The most common exclusion criteria were pregnancy (n = 31 trials), SAH due to other causes (trauma, fusiform or mycotic aneurysm, n = 26 trials) and significant liver disease/hepatic insufficiency (n = 19 trials). CONSORT was used in 16(23.5%) trials and 18 (16.5%) trials provided the proportion of patients excluded according to each of the exclusion criteria. In a single center cohort, the highest proportion of patients were excluded because no aneurysm was identified on imaging (23%) followed by withdrawal of care (9.6%) and need for dual anti-platelet treatment (8.6%). The in-hospital mortality was higher in patients who were excluded as compared with those who were included in the hypothetical trial (22 [30.1%] of 73 and 0 [0%] of 31 patients).

CONCLUSIONS

Our analysis on exclusion criteria used and proportion of patients excluded in clinical trials involving SAH patients will assist in future trial enrollment, completion, and generalizability. Standardized reporting using CONSORT in clinical trials involving SAH patients is strongly recommended.

State-of-the-art for automated machine learning predicts outcomes in poor-grade aneurysmal subarachnoid hemorrhage using routinely measured laboratory & radiological parameters: coagulation parameters and liver function as key prognosticators

The objective of this study was to develop and evaluate automated machine learning (aML) models for predicting short-term (1-month) and medium-term (3-month) functional outcomes [Modified Rankin Scale (mRS)] in patients suffering from poor-grade aneurysmal subarachnoid hemorrhage (aSAH), using readily available and routinely measured laboratory and radiological parameters at admission. Data from a pilot non-randomized trial of 60 poor-grade aSAH patients (Hunt-Hess grades IV or V) were analyzed. Patients were evenly divided between targeted temperature management (TTM) and standard treatment groups. The current state-of-the-art for aML was adopted to employ nine ML algorithms with hyperparameter tuning to develop algorithmic models predicting 1 month and 3-months mRS scores. Model performance was evaluated using macro-weighted average Area Under the Receiver Operating Curve (mWA-AUROC) analysis and additional metrics. Logistic regression algorithmic models achieved perfect prediction (mWA-AUROC = 1, accuracy = 100%, sensitivity and specificity = 100% [95% CI: 83.16 - 100%]) for both 1-month and 3-month mRS outcomes. For 1-month outcomes, neutrophil count, platelet count, and gamma-glutamyl transferase levels were identified as key predictors. For 3-month outcomes, patient gender, activated partial thromboplastin time, and serum aspartate aminotransferase levels were most impactful. Decision tree algorithms (mWA-AUROC = 0.9-0.925) identified specific cut-points for various parameters, providing actionable information for clinical decision-making. Positive prognostic factors included alkaline phosphatase levels higher than mid-value of their normal range, absence of hydrocephalus, use of targeted temperature management (TTM), and specific cut-offs for coagulation and liver function parameters. The use of TTM was reinforced as a key prognosticator of mRS outcomes at both time points. We have made our developed models and the associated architecture available at GitHub. This study demonstrated the potential of aML in predicting functional outcomes for poor-grade aSAH patients. The identification of novel predictors, including liver function and coagulation parameters, opens new avenues for research and intervention. While the perfect predictive performance warrants cautious interpretation and further validation, these models represent a step towards personalized medicine in aSAH management, potentially improving prognostication and treatment strategies.

Hyponatremia Incidence After Subarachnoid Hemorrhage and Association with Outcomes: Systematic Review and Meta-Analysis

OBJECTIVE

Hyponatremia after aneurysmal subarachnoid hemorrhage (aSAH) is common; however, the incidence, and association with vasospasm, morbidity, and mortality, has yet to be defined. We aimed to identify incidence of hyponatremia after aSAH, and quantify its association with measurable outcomes.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review and meta-analysis was conducted (international prospective register of systematic reviews ID CRD42022363472). Articles published in MEDLINE, Embase, and Cochrane Library between January 1990 and January 2024 were included. Hyponatremia definitions, incidence during admission, and association among vasospasm, length of hospital stay, and poor outcome (Glasgow Outcome Scale 3 or less) were identified. Pooled incidence rates and binary and continuous outcomes were calculated using random effects meta-analysis models.

RESULTS

In total, 52 studies (10,512 patients) were included. Most studies included patients admitted to tertiary neuroscience centers (61.5%, N = 32), or critical care units (23.1%, N = 11). Sodium of less than 135 mmol/L was the most commonly used hyponatremia definition (84.6%, N = 44). The pooled incidence of hyponatremia was 37.0% (95% confidence interval [CI]: 31.7%-42.4%). Hyponatremia increased the risk of vasospasm (15 studies; odds ratio: 2.93; 95% CI: 1.77-4.84), and length of hospital stay (3 studies, 16.4 days vs. 8.0 days, mean difference 8.5 [95% CI: 4.6-12.4]), but was not associated with poor outcome (10 studies; odds ratio 1.15; 95% CI 0.44-3.02). These findings remained when carrying out sensitivity analysis for different hyponatremia and outcome definitions, bias, and aSAH populations.

CONCLUSIONS

Hyponatremia is common in aSAH, may increase the likelihood of vasospasm, but in isolation does not appear to affect overall outcomes. Managing hyponatremia effectively should be a priority for treating clinicians.

Prevention of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage-Summary of Existing Clinical Evidence

The 2023 International Subarachnoid Hemorrhage Conference identified a need to provide an up-to-date review on prevention methods for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage and highlight areas for future research. A PubMed search was conducted for key factors contributing to development of delayed cerebral ischemia: anesthetics, antithrombotics, cerebrospinal fluid (CSF) diversion, hemodynamic, endovascular, and medical management. It was found that there is still a need for prospective studies analyzing the best methods for anesthetics and antithrombotics, though inhaled anesthetics and antiplatelets were found to have some advantages. Lumbar drains should increasingly be considered the first line of CSF diversion when applicable. Finally, maintaining euvolemia before and during vasospasm is recommended as there is no evidence supporting prophylactic spasmolysis or angioplasty. There is accumulating observational evidence, however, that intra-arterial spasmolysis with refractory DCI might be beneficial in patients not responding to induced hypertension. Nimodipine remains the medical therapy with the most support for prevention.

Regulatory T Cell- and Natural Killer Cell-Mediated Inflammation, Cerebral Vasospasm, and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage-A Systematic Review and Meta-Analysis Approach

Aneurysmal subarachnoid hemorrhage (SAH) involves a significant influx of blood into the cerebrospinal fluid, representing a severe form of stroke. Despite advancements in aneurysm closure and neuro-intensive care, outcomes remain impaired due to cerebral vasospasm and delayed cerebral ischemia (DCI). Previous pharmacological therapies have not successfully reduced DCI while improving overall outcomes. As a result, significant efforts are underway to better understand the cellular and molecular mechanisms involved. This review focuses on the activation and effects of immune cells after SAH and their interactions with neurotoxic and vasoactive substances as well as inflammatory mediators. Particular attention is given to clinical studies highlighting the roles of natural killer (NK) cells and regulatory T cells (Treg) cells. Alongside microglia, astrocytes, and oligodendrocytes, NK cells and Treg cells are key contributors to the inflammatory cascade following SAH. Their involvement in modulating the neuro-inflammatory response, vasospasm, and DCI underscores their potential as therapeutic targets and prognostic markers in the post-SAH recovery process. We conducted a systematic review on T cell- and natural killer cell-mediated inflammation and their roles in cerebral vasospasm and delayed cerebral ischemia. We conducted a meta-analysis to evaluate outcomes and mortality in studies focused on NK cell- and T cell-mediated mechanisms.

Safety and efficacy of staged primary coiling followed by delayed flow diversion of ruptured intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

Ruptured intracranial aneurysms lead to significant mortality and morbidity. Recent advancements have suggested staged coiling with subsequent flow diverter stent placement may reduce the risk of hemorrhage with dual antiplatelet therapy (DAPT) or stent thrombosis in the acute inflammatory phase after aneurysm rupture while still appropriately mitigating risk of aneurysmal rehemorrhage.

MATERIALS AND METHODS

A systematic review and single-arm meta-analysis was conducted. Studies reporting patients receiving coiling followed by delayed flow diverter placement on a separate day were included.

RESULTS

Five studies, comprising 94 patients, were included for meta-analysis. Average time between procedures ranged from 9.8 to 169 days; 24% (95% CI: 10-41%) of patients had a poor functional neurologic outcome (modified Rankin Scale > 2) at discharge compared to 4% (0-11%) at last follow-up. There was one incidence of rehemorrhage between treatments, 0% (0-4%). Vasospasm after coiling was the most common adverse event, 16% (1-41%). There was low risk of ischemic complications [1% (0-8%) with coil placement and 5% (1-11%) with stent placement]. Intraprocedural intracranial hemorrhage was also rare (two patients during coil placement; no cases during stent placement). There were no significant differences if flow diversion was performed less than or greater than 100 days from coiling.

CONCLUSIONS

Our study highlights the benefit of primary coiling with staged flow diversion for the management of ruptured intracranial aneurysms with a low risk for complications. Namely, the rate of rebleeding between treatments was exceptionally low. We advocate for the greater consideration of this treatment combination in the treatment of ruptured intracranial aneurysms.

Comparison of the Safety of Aspirin Monotherapy and Aspirin and P2Y12 Inhibitor Combination Therapy in Patients Post Coil Embolization During Admission: A Cross-Sectional Study Using a Nationwide Inpatient Database

BACKGROUND

Some aspects regarding the use of antiplatelet agents after coil embolization for subarachnoid hemorrhage during admission remain unclear. This study used diagnostic procedure combination (DPC) data to investigate the safety and prognostic effects of aspirin monotherapy and aspirin and P2Y12 inhibitor combination therapy on bleeding events.

METHODS

This cross-sectional study used Japanese DPC data to assess patients who were hospitalized with subarachnoid hemorrhage and received aspirin monotherapy and aspirin and P2Y12 inhibitor combination therapy between April 2016 and March 2020 (n = 4421). The aspirin monotherapy (A group, n = 2848) and aspirin and P2Y12 inhibitor combination therapy (AP group, n = 1573) groups were compared. The primary and secondary endpoints were the incidence of bleeding events and proportion of patients with a modified Rankin Scale (mRS) score ≤ 2 at discharge, respectively. Data was analyzed using multivariable adjusted logistic regression (significance level, 5%).

RESULTS

The adjusted odds ratio in AP group, with A group as the reference, for bleeding events and the proportion of patients with mRS score ≤ 2 at discharge were 0.97 (95% confidence interval [95% CI]: 0.75-1.26, p = 0.839) and 1.09 (95% CI: 0.92-1.29, p = 0.302), respectively.

CONCLUSIONS

There are no differences in the incidence of bleeding events or good clinical outcomes (mRS score ≤ 2 at discharge) between aspirin monotherapy and aspirin and P2Y12 inhibitor combination therapy.

Prevalence, trends, and outcomes of cerebral infarction in patients with aneurysmal subarachnoid hemorrhage in the USA

BACKGROUND AND PURPOSE

Cerebral infarction remains an important cause of death or disability in patients with aneurysmal subarachnoid hemorrhage (SAH). The prevalence, trends, and outcomes of cerebral infarction in patients with aneurysmal SAH at a national level are not known.

METHODS

We identified the proportion of patients who develop cerebral infarction (ascertained using validated methodology) among patients with aneurysmal SAH and annual trends using the Nationwide Inpatient Sample (NIS) from 2016 to 2021. We analyzed the effect of cerebral infarction on in-hospital mortality, routine discharge without palliative care (based on discharge disposition), poor outcome defined by the NIS SAH outcome measure, and length and costs of hospitalization after adjusting for potential confounders.

RESULTS

A total of 35,305 (53.6%) patients developed cerebral infarction among 65,840 patients with aneurysmal SAH over a 6-year period. There was a trend toward an increase in the proportion of patients who developed cerebral infarction from 51.5% in 2016 to 56.1% in 2021 (p trend p<.001). Routine discharge was significantly lower (30.5% vs. 37.8%, odds ratio [OR] 0.82, 95% confidence interval [CI] 0.75-0.89, p<.001), and poor outcome defined by NIS-SAH outcome measure was significantly higher among patients with cerebral infarction compared with those without cerebral infarction (67.4% vs. 59.3%, OR 1.29, 95% CI 1.18-1.40, p<.001). There was no difference in in-hospital mortality (13.0% vs. 13.6%, OR 0.94, 95% CI 0.85-1.05, p = .30). The length of stay (median 18 days [interquartile range [IQR] 13-25] vs. 14 days [IQR 9-20]), coefficient 3.04, 95% CI 2.44-3.52 and hospitalization cost (median $96,823 vs. $71,311, coefficient 22,320, 95% CI 20,053-24,587) were significantly higher among patients who developed cerebral infarction compared with those who did not develop cerebral infarction.

CONCLUSIONS

Cerebral infarction was seen in 54% of the patients with a trend toward an increase in the affected proportion of patients with aneurysmal SAH. Patients with cerebral infarction had higher rates of adverse outcomes and required higher resources during hospitalization.

The delicate nature of a constructive peer review: pearls from the editorial board

Peer review stands as a cornerstone of academic publishing, especially in the era of evidence-based neurosurgery - the scientific literature relies on proficient peer reviewers. Providing a constructive peer review is an art and learned skill that requires knowledge of study design and expertise in the neurosurgical subspeciality. Peer reviewers guard against arbitrary decision-making and are essential in ensuring that published manuscripts are of the highest quality. However, there remains a scarcity in the formal training relating to the peer review process. The objective of this article is therefore to shed light on this process through the lens of the Editorial Board. We encourage our invited peer reviewers to make use of this guide when appraising potential manuscripts.

Predictive value of the systemic immune-inflammation index for periprocedural complications in flow diverter treatment for patients with intracranial aneurysms

Flow-diverter devices (FDs) are effective in treating intracranial aneurysms (IAs) but carry substantial periprocedural risks, particularly ischemic complications. This study aimed to determine if elevated Systemic Immune-Inflammation Index (SII) can independently predict these risks and assess the impact of age and dual antiplatelet therapy on this association. We conducted a retrospective analysis of patients treated with FDs between February 2016 and August 2023, using blood samples taken within six days before surgery to calculate SII. Logistic regression and decision tree analyses assessed the link between SII and periprocedural complications, with subgroups exploring influencing factors. Multivariable analysis identified high SII as an independent predictor of periprocedural complications (OR = 5.306, 95% CI: 1.367-18.455; P = 0.009). The decision tree model confirmed SII > 0.437 as a critical threshold. Subgroup analysis showed a pronounced association of SII with periprocedural complications in patients ≥ 65 years (OR = 36.979, 95% CI: 2.103-650.134; P = 0.014) and in those on clopidogrel plus aspirin therapy (OR = 16.921, 95% CI: 2.733-104.746; P = 0.002). An elevated Systemic Immune-Inflammation Index (SII) > 0.437 significantly correlates with increased periprocedural complications (6.5% vs. 1.8%, P = 0.017). Although not statistically significant, higher SII is associated with a greater rate of ischemic events (3.9% vs. 0.9%). Elevated preoperative SII independently predicts periprocedural complications, particularly ischemic events, in patients undergoing FDs treatment for intracranial aneurysms. This association is particularly pronounced in older patients (> 65 years) and those receiving dual therapy with clopidogrel plus aspirin. Trial Registration: ClinicalTrials.gov (NCT06446778). Registered on May 22, 2024.

Systematic reviews and meta-analyses in neurosurgery Part II: a guide to designing the protocol

Despite clearly established guidelines, recent audits have found the conduct and reporting of systematic reviews and meta-analyses (SRMAs) within neurosurgery to be relatively lackluster in methodological rigor and compliance. Protocols of SRMAs allow for planning and documentation of review methods, guard against arbitrary decision-making during the review process, and enable readers to assess for the presence of selective reporting. To aid transparency, authors should provide sufficient detail in their protocol so that the readers could reproduce the study themselves. Development of our guideline drew heavily from the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols (PRISMA-P) initiative. The objective of this article is not to enumerate every detail of this checklist, but to provide guidance to authors preparing their protocol, with examples, for a systematic review in neurosurgery. Particularly, we emphasize on the PICO framework - population (P), interventions (I), comparators (C), outcomes (O) - which is central to constructing a clinical question, defining the scope of the systematic review, defining and prioritizing the primary outcome, to specifying the eligibility criteria, designing the search strategy, and identifying potential sources of heterogeneity. We encourage our readers to make use of this guideline alongside the PRISMA-P 2015 statement, when drafting and appraising systematic review protocols.

Systematic reviews and meta-analyses in neurosurgery part I: interpreting and critically appraising as a guide for clinical practice

Neurosurgeons are inundated with the Herculean task to keep abreast with the rapid pace at which clinical research is proliferating. Systematic reviews and meta-analyses (SRMAs) have consequently surged in popularity because when executed properly, they constitute the highest level of evidence, and may save busy neurosurgeons many hours of combing the literature. Well-executed SRMAs may prove instructive for clinical practice, but poorly conducted reviews sow confusion and may potentially cause harm. Unfortunately, many SRMAs within neurosurgery are relatively lackluster in methodological rigor. When neurosurgeons apply the results of an SRMA to patient care, they should start by evaluating the extent to which the employed methods have likely protected against misleading results. The present article aims to educate the reader about how to interpret an SRMA, to assess the potential relevance of its results in the special context of the neurosurgical patient population.

Incidence and Risk Factors of Surgical Site Infection After Cranial Surgery for Patients with Brain Tumors: A Systematic Review and Meta-analysis

BACKGROUND

Surgical site infections after craniotomy (SSI-CRANs) are a serious adverse event given the proximity of the wound to the central nervous system. SSI-CRANs are associated with substantial patient morbidity and mortality. Despite the importance and recognition of this event in other surgical fields, there is a paucity of evidence in the neurosurgical literature devoted to SSI-CRAN specifically in patients after brain tumor surgery.

METHODS

Systematic searches of Medline, Embase, and Cochrane Central were undertaken. The primary outcome was the incidence of SSI-CRAN at 30 and 90 days. Secondary outcomes were risk factors for SSI-CRAN.

RESULTS

Thirty-seven studies reporting 91,907 patients with brain tumors who underwent cranial surgery were included in the meta-analysis. Pooled incidence of SSI-CRAN at 30 and 90 days was 4.03% (95% CI: 2.94%-5.28%, I2 = 97.3) and 6.17% (95% CI: 3.16%-10.07%, I2 = 97.3), respectively. Specifically, incidence of SSI-CRAN following surgery for posterior fossa tumors was the highest at 9.67% (95% CI: 5.98%-14.09%, I2 = 75.5). Overall pooled incidence of readmission within 30 days and reoperation due to SSI-CRAN were 13.9% (95% CI: 12.5%-15.5%, I2 = 0.0) and 16.3% (95% CI: 5.4%-31.3%, I2 = 72.9), respectively. Risk factors for SSI-CRAN included reintervention (risk ratio [RR] 1.58, 95% CI: 1.22-2.04, I2 = 0.0), previous radiotherapy (RR 1.69, 95% CI: 1.20-2.38, I2 = 0.0), longer duration of operation (mean difference 64.18, 95% CI: 3.96-124.40 minutes, I2 = 90.3) and cerebrospinal fluid (CSF) leaks (RR 14.26, 95% CI: 2.14-94.90, I2 = 73.2).

CONCLUSIONS

SSI-CRAN affects up to 1 in 14 patients with brain tumors. High-risk groups include those with reintervention, previous radiotherapy, longer duration of operation, and CSF leaks. Further prospective studies should focus on bundles of care that will reduce SSI-CRAN.

Effectiveness of Cerebrospinal Fluid Lumbar Drainage Among Patients with Aneurysmal Subarachnoid Hemorrhage: An Updated Systematic Review and Meta-Analysis

INTRODUCTION

Cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage (aSAH) continues to be a major source of morbidity despite significant clinical and basic science research. The removal of blood and its degradation products from the subarachnoid space through prophylactic lumbar drainage (LD) is a favorable option. However, several studies have delivered conflicting conclusions on its efficacy after aSAH.

METHODS

Systematic searches of Medline, Embase, and Cochrane Central Register of Controlled Trials were performed. The primary outcome was a good functional outcome (modified Rankin scale score, 0-2). Secondary outcomes included symptomatic vasospasm, secondary cerebral infarction, and mortality.

RESULTS

A total of 14 studies reporting on 2473 patients with aSAH were included in the meta-analysis. Compared with the non-LD group, no significant differences were found in the rates of good functional outcomes in the LD group at discharge to 1 month (risk ratio [RR], 1.28; 95% confidence interval [CI], 0.64-2.58) or at 6 months (RR, 1.12; 95% CI, 0.97-1.41). These findings were consistent in the subgroup analyses of only randomized controlled trials or observational studies. LD was associated with lower rates of symptomatic vasospasm (RR, 0.61; 95% CI, 0.48-0.77), secondary cerebral infarction (RR, 0.59; 95% CI, 0.45-0.79), and mortality at discharge to 1 month (RR, 0.58; 95% CI, 0.41-0.82). The effect on mortality diminished at 6 months (RR, 0.70; 95% CI, 0.34-1.45). However, when analyzing only randomized controlled trials, the benefit of LD on lower rates of mortality continued even at 6 months (RR, 0.75; 95% CI, 0.58-0.99).

CONCLUSIONS

For aSAH patients, the use of LD is associated with benefits in the rates of vasospasm, secondary cerebral infarctions, and mortality, without an increased risk of adverse events.

Endovascular coiling versus neurosurgical clipping in the management of aneurysmal subarachnoid haemorrhage in the elderly: a multicenter cohort study

The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0-2 at 3 months (OR = 2.45 [95%CI:1.16-5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10-0.91];p = 0.026). There were no significant difference between the two treatment groups in terms of good mRS score at 6 months (OR = 1.98 [95%CI:0.97-4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12-0.90];p = 0.025). Age, admission WFNS score I-III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I-III remained significant predictors of good functional outcomes at 6 months. Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.

Neurosurgical clipping versus endovascular coiling for patients with ruptured anterior circulation aneurysms: A systematic review and meta-analysis

To compare the safety and efficacy of clipping and coiling in patients with ruptured anterior circulation aneurysms. A systematic search of four databases (PubMed, Web of Science, Cochrane Library, and Embase) was conducted to identify comparative articles on endovascular coiling and surgical clipping in patients with ruptured anterior circulation aneurysms. Meta-analyses were conducted using random-effects models. Nineteen studies, including 1983 patients, were included. The meta-analysis showed that neurosurgical clipping was associated with a lower incidence of retreatment (OR:0.28, 95% CI (0.11, 0.70), P = 0.006) than endovascular coiling, which seemed to be a result of incomplete occlusion (OR:0.22, 95% CI (0.11, 0.45), P < 0.001). Neurosurgical clipping was associated with lower mortality (OR:0.45, 95% CI (0.25, 0.82), P = 0.009) at short-term follow-up than endovascular coiling. However, neurosurgical clipping showed a higher incidence of ischemic infarction (OR:2.28, 95% CI (1.44, 3.63), P < 0.001) and a longer length of stay (LOS) (WMD:6.12, 95% CI (4.19, 8.04), P < 0.001) after surgery than endovascular coiling. Furthermore, the pooled results showed no statistically significant differences between the two groups regarding poor outcome, long-term mortality, rebleeding, vasospasm, and hydrocephalus. Evidence from this systematic review illustrates that neurosurgical clipping may be superior to endovascular coiling for ruptured anterior circulation aneurysms. Large-scale RCTs should be conducted to verify these outcomes and provide results according to patient status.