Endovascular management of internal carotid artery terminus aneurysms: a systematic review and meta-analysis

Internal carotid artery (ICA) terminus aneurysms are a rare subtype of intracranial aneurysms with distinct hemodynamic characteristics and treatment challenges. This study aims to evaluate clinical outcomes associated with different endovascular approaches for ICA terminus aneurysms through a systematic review and meta-analysis. A comprehensive literature search through PubMed and Scopus from inception to July 2025. Data on patient demographics, aneurysm characteristics, and outcomes of coil embolization, stent-assisted coiling, and FD were extracted. Pooled analyses and subgroup comparisons were performed following PRISMA guidelines. Among 322 patients, primary coil embedding (59.0%) was the most used modality, followed by stent-assisted coiling (30.1%) and flow diversion (FD) (10.2%). A good functional outcome (mRS 0–2) was achieved in 74.5%, and complete occlusion in 72.4%. Primary coil embedding demonstrated significantly lower stroke (OR = 0.193, 95% CI: 0.056–0.662) and mortality (OR = 0.234, 95% CI: 0.045–0.906) compared to FD. Stent-assisted coiling achieved the highest rate of favorable outcomes (97.7%) and lowest recurrence (8.1%). Ruptured aneurysms were associated with worse outcomes, including lower occlusion (41–59%) and higher mortality (9.4%) than unruptured cases (occlusion: 94.5%, mortality: 2.0%). Endovascular strategies are commonly used in the management of ICA terminus aneurysms and demonstrate overall acceptable clinical and radiographic outcomes in contemporary practice. Observed differences among treatment modalities likely reflect underlying aneurysm morphology, clinical context, and treatment selection rather than intrinsic differences in device performance. Therefore, modality choice should be individualized based on anatomical and clinical considerations, and current findings should be interpreted as descriptive and hypothesis-generating. ICA terminus aneurysms are uncommon (~2–9% of intracranial aneurysms), tend to present younger/smaller, and are driven by terminus hemodynamics; coiling is the historical mainstay, with FDs/intrasaccular options explored in selected anatomies, but comparative evidence is fragmented. This PRISMA-based review (Inception–Jul 2025) synthesizes 17 studies/322 patients and quantifies modality-specific outcomes: primary coil embedding (59%), stent-assisted coiling (30%), flow diversion (10%) with overall mRS 0–2 of 74.5% and complete occlusion 72.4%; primary coil embedding showed lower postoperative stroke (OR 0.193) and mortality (OR 0.234) versus flow diversion, while stent-assisted coiling achieved high good outcomes (97.7%) and low recurrence (8.1%). For ICA terminus aneurysms, endovascular therapy is widely used and associated with acceptable outcomes in contemporary practice. Apparent differences across treatment modalities likely reflect patient selection, aneurysm morphology, rupture status, and operator preference rather than intrinsic differences in treatment efficacy or safety. These findings support individualized treatment selection and highlight the need for prospective, rupture-stratified studies to better define optimal indications.