Vision Outcomes in Patients With Paraclinoid Aneurysms Treated With Clipping, Coiling, or Flow Diversion: A Systematic Review and Meta-Analysis

Abstract

OBJECTIVE Patients with paraclinoid aneurysms commonly present with visual impairment. They have traditionally been treated with clipping or coiling, but ow diversion (FD) has recently been introduced as an alternative treatment mo- dality. Although there is still initial aneurysm thrombosis, FD is hypothesized to reduce mass effect, which may decom- press the optic nerve when treating patients with visually symptomatic paraclinoid aneurysms. The authors performeda meta-analysis to compare vision outcomes following clipping, coiling, or FD of paraclinoid aneurysms in patients who presented with visual impairment. METHODS A systematic literature review was performed using the PubMed and Web of Science databases. Studies published in English between 1980 and 2016 were included if they reported preoperative and postoperative visual func- tion in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic seg- ment) treated with clipping, coiling, or FD. Neuroophthalmological assessment was used when reported, but subjective patient reports or objective visual examination ndings were also acceptable. RESULTS Thirty-nine studies that included a total of 2458 patients (520 of whom presented with visual symptoms) met the inclusion criteria, including 307 visually symptomatic cases treated with clipping (mean follow-up 26 months), 149 treated with coiling (mean follow-up 17 months), and 64 treated with FD (mean follow-up 11 months). Postoperative vi- sion in these patients was classi ed as improved, unchanged, or worsened compared with preoperative vision. A pooled analysis showed preoperative visual symptoms in 38% (95% CI 28%–50%) of patients with paraclinoid aneurysms. The authors found that vision improved in 58% (95% CI 48%–68%) of patients after clipping, 49% (95% CI 38%–59%) after coiling, and 71% (95% CI 55%–84%) after FD. Vision worsened in 11% (95% CI 7%–17%) of patients after clipping, 9% (95% CI 2%–18%) after coiling, and 5% (95% CI 0%–20%) after FD. New visual de cits were found in patients with intact baseline vision at a rate of 1% (95% CI 0%–3%) for clipping, 0% (95% CI 0%–2%) for coiling, and 0% (95% CI 0%–2%) for FD. CONCLUSIONS To the authors’ knowledge, this is the rst meta-analysis to assess vision outcomes after treatment for paraclinoid aneurysms. The authors found that 38% of patients with these aneurysms presented with visual impairment. These data also demonstrated a high rate of visual improvement after FD without a signi cant difference in the rate of worsened vision or iatrogenic visual impairment compared with clipping and coiling. These ndings suggest that FD is an effective option for treatment of visually symptomatic paraclinoid aneurysms.