Comparative Analysis of Stent-Assisted Versus Non-Stent-Assisted Coiling in the Management of Ruptured Intracranial Aneurysms: A Systematic Review and Meta-Analysis

Translational Stroke Research https://doi.org/10.1007/s12975-024-01314-0 REVIEW Comparative Analysis of Stent‑Assisted Versus Non‑Stent‑Assisted Coiling in the Management of Ruptured Intracranial Aneurysms: A Systematic Review and Meta‑Analysis Yu‑Hu Ma1 · Yong‑Lin He2 · Xiao‑Yue Zhang3 · Rui Shang1 · Hai‑Tao Hu1 · Ting Wang1 · Sen Lin1 · Ya‑Wen Pan2 · Chang‑Wei Zhang1 Received: 7 July 2024 / Revised: 18 November 2024 / Accepted: 22 November 2024 © The Author(s) 2024 Abstract Objective To systematically evaluate the safety and efficacy of SAC compared to non-SAC in the treatment of RIA, integrating evidence from high-quality studies to guide clinical practice. Methods A meta-analysis was conducted to compare SAC with coiling alone and BAC in the treatment of RIA. Primary outcomes were immediate and follow-up aneurysm occlusion rates, along with perioperative hemorrhagic and ischemic complication rates. Results A total of thirteen retrospective cohort studies were included, comprising 3,086 patients, with 1,078 in the SAC group and 2,008 in the non-SAC group. The immediate complete occlusion rates were similar between the SAC and non-SAC groups (59.1% vs. 61.4%; RR = 1.00; 95% CI [0.94, 1.07]; p = 0.92). However, the SAC group demonstrated a significantly higher long-term complete occlusion rate (61.3% vs. 40.6%; RR = 1.44; 95% CI [1.22, 1.69]; p < 0.001). The incidence of ischemic complications was greater in the SAC group (12.2% vs. 10.0%; RR = 1.68; 95% CI [1.37, 2.07]; p < 0.001), as was the incidence of hemorrhagic complications (7.3% vs. 5.1%; RR = 1.55; 95% CI [1.15, 2.08]; p = 0.004). Perioperative mortality was also elevated in the SAC group (6.7% vs. 6.8%; RR = 1.37; 95% CI [1.00, 1.88]; p = 0.048), with a non-significant trend towards higher long-term mortality (9.8% vs. 9.2%; RR = 1.35; 95% CI [0.98, 1.87]; p = 0.068). Functional outcomes at discharge (76.0% vs. 71.0%; RR = 0.97; 95% CI [0.92, 1.02]; p = 0.237), six months (57.8% vs. 60.8%; RR = 0.93; 95% CI [0.81, 1.07]; p = 0.296), and at the last follow-up (RR = 1.01; 95% CI [0.97, 1.06]; p = 0.592) were comparable between the two groups. Conclusions SAC significantly improves long-term occlusion rates for RIA compared to non-SAC, despite a higher incidence of complications. Careful patient selection and optimization of antiplatelet therapy may enhance the safety and efficacy of SAC for RIA treatment. Keywords Ruptured intracranial aneurysms · Aneurysmal subarachnoid hemorrhage · Stent-assisted coiling · Balloonassisted coiling · Meta-analysis Introduction Yu-Hu Ma and Yong-Lin He contributed equally to this work. * Chang‑Wei Zhang 1 Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China 2 Department of Neurosurgery, The Second Hospital of Lanzhou University, Lanzhou, China 3 The First Clinical Medical College of Lanzhou University, Lanzhou, China Intracranial aneurysms (IA) present as localized pathological dilatations of the arterial walls within the cranium. The rupture of IA is associated with 50–80% of subarachnoid hemorrhage (SAH), leading to a mortality rate of up to 40% within the first week and accounting for 5–8% of all stroke cases [1–5]. The high morbidity and mortality associated with ruptured intracranial aneurysms (RIA) underscore the urgent need for effective diagnostic and therapeutic strategies. Since the International Subarachnoid Aneurysm Trial (ISAT) in 2005, endovascular coiling has been established as Vol.:(0123456789) Translational Stroke Research the standard treatment for RIA due to its lasting efficacy [6–8]. The intricate nature and location of some aneurysms require the use of intracranial stents to assist in coiling, preventing coil protrusion into the parent artery and maintaining arterial patency. Stent-assisted coiling (SAC) facilitates denser coil packing and has demonstrated to be safe and effective, particularly in the management of unruptured aneurysms [9–12]. However, compared to unruptured aneurysms, the application of SAC in RIA is associated with increased risks of procedural complications and mortality [13–15]. Despite the increasing use of flow-diverter devices (FDs) for some aneurysm types, SAC and coiling alone remain primary treatments for RIA in many regions where FDs is not yet widely approved for ruptured aneurysms. In light of these elevated risks, assessing SAC's safety and efficacy in RIA remains essential to guide optimal treatment choices. The hypercoagulable state during the acute phase of SAH may lead to intrastent thrombosis, necessitating the use of dual antiplatelet therapy to mitigate thrombotic events [16–18]. However, the use of dual antiplatelet drugs increases the risk of aneurysm rebleeding and hemorrhagic complications, which can complicate surgical interventions in the acute SAH phase [19–21]. Additionally, supplementary surgical interventions, such as external ventricular drain (EVD), decompressive craniectomy, or ventriculo-peritoneal (VP) shunt, may further increase the risk of bleeding [22–24]. Current research indicates that the overall incidence of thromboembolic and hemorrhagic complications during the perioperative period for SAC in RIA is approximately 20.2% [25]. Consequently, the 2012 American Heart Association/American Stroke Association (AHA/ASA) guidelines on the treatment of aSAH recommend considering SAC only after excluding less risky alternatives [26]. However, with ongoing advancements in management of antiplatelet therapy, endovascular techniques, and surgeon proficiency, several studies suggest that the perioperative complication rates between SAC and traditional coil embolization are comparable [27]. A recent meta-analysis suggest that SAC may offer better rates of aneurysm occlusion and reduced recurrence at follow-up compared to traditional coiling [25]. These seemingly contradictory perspectives underscore the lack of a proper assessment of the safety and efficacy of SAC in treating RIA. Thus, we conducted this systematic review and meta-analysis to critically assess the safety and efficacy of SAC versus non-SAC in managing RIAs, integrating evidence from high-quality research to guide clinical practice. Methods and Materials Protocol and Registration This systematic review and meta-analysis adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines and recommendations [28]. The study protocol was not formally registered on any online platform. As all analyses relied on previously published studies, ethical approval or patient consent was not required. Eligibility Criteria Selection of studies was based on the following criteria: (1) Patients diagnosed with RIA confirmed by Digital Subtraction Angiography (DSA) as the study population. (2) Comparison of the safety and efficacy of SAC with either coil embolization or balloon-assisted coiling (BAC). (3) Studies reporting predefined primary outcomes for this metaanalysis (...truncated)