Unruptured Paraclinoid Aneurysm Treatment Effects on Visual Function: A Systematic Review and Meta-Analysis

Aim: Postoperative visual outcomes following elective repair of unruptured paraclinoid aneurysms (UPAs) are not well defined. The objective of this study was to investigate the influence of treatment modality on visual function.

Methods: A systematic literature analysis using the Ovid Medline and EMBASE electronic databases was performed, encompassing all English language studies (published between 1996 and 2016) reporting visual, clinical, and angiographic treatment outcomes for UPAs. Rates of visual morbidity (any new, permanent postoperative deficit in visual acuity or visual field, or worsening of a preoperative deficit), angiographic (recurrence, retreatment) and clinical outcomes (death and dependency, post-treatment subarachnoid hemorrhage (SAH)) were extracted and analyzed. Random effects meta-analysis was performed for comparative studies.

Results: Twenty-eight studies reported on postoperative visual outcomes, with data available for 1,013 endovascular and 691 microsurgical patients. In patients with normal vision undergoing repairs for UPAs, rates of postoperative visual morbidity were higher following microsurgical (10.8%; 95%CI 8.5–13.7) than endovascular (2.0%; 95%CI 1.2–3.2) interventions, p < 0.001. In those with preoperative visual impairment, surgery was associated with a modest advantage in visual recovery as compared with endovascular therapies (65.2% vs 48.9%, p < 0.03). There were no differences in visual morbidity following treatment with any of the endovascular modalities (coil embolization, stent-assisted coiling, or flow diverters). Meta-analysis of comparative studies suggested a trend toward poor visual (ES = 0.42; 95%CI 0.08–2.09) and clinical outcomes (ES = 0.57; 95%CI 0.07–4.44) following microsurgery, and a trend toward angiographic recurrence (ES = 2.52; 95% CI 0.80–7.90) and retreatment (ES = 1.62; 95% CI 0.46–5.67) toward endovascular interventions.

Conclusions: In patients with normal vision undergoing repairs for UPAs, there is a positive correlation between visual outcomes and endovascular treatments. When visual compromise is present, surgery provided modest advantage in visual recovery. However, definitive conclusions were not possible due to data heterogeneity.