Objective:

To compare outcomes between complex endovascular aneurysm repair (C-EVAR) and surgical clipping in patients with ruptured cerebral aneurysms not amenable to conventional coiling.

Background:

Endovascular techniques for cerebral aneurysm repair continue to evolve. Current guidelines favor coiling for most cases of aneurysmal subarachnoid hemorrhage (aSAH). However, when aneurysms are not suitable for coiling, the optimal treatment approach remains uncertain. Options include surgical clipping or C-EVAR, such as flow diverters or stent-assisted coiling.

Design/Methods:

We conducted a retrospective review of consecutive aSAH patients treated at two academic centers (2016 to 2024 at one center, 2019 to 2024 at the other). Multivariable logistic and linear regression analyses were used to evaluate associations between treatment modality and outcomes. Outcomes included poor functional status at 3 months (defined as modified Rankin Scale [mRS] 3 to 6), discharge disposition, presence of cerebral infarction during hospitalization, and hospital length of stay.

Results:

Among 696 aSAH patients (mean age 57.8 years [SD 14.4], 65% female, 63% White), 123 (18%) underwent clipping and 169 (24%) received C-EVAR. Patients treated with clipping were younger (mean 52.8 vs. 57.9 years; p = 0.015) and less frequently White (54% vs. 67%; p = 0.016). Clipping was associated with higher odds of cerebral infarction (OR 1.8, 95% CI 1.12 to 2.85; p = 0.014), independent of age, Hunt and Hess grade, and modified Fisher score. There were no significant differences in poor functional outcome or discharge to long-term care between groups. Among survivors, hospital stay was longer for the clipping group (β = 3.2 days, 95% CI 0.4 to 6.0; p = 0.025).

Conclusions:

Although clipping was associated with higher rates of infarction and longer hospitalization, short-term functional outcomes were similar to those of patients treated with C-EVAR. Larger prospective studies are needed to assess long-term outcomes.