Comparative analysis of surgical and endovascular aneurysm repair in subarachnoid hemorrhage: a single-center study with 1,171 patients

Abstract Background To compare surgical and endovascular therapy (EVT) approaches to aneurysm repair in all aneurysmal subarachnoid hemorrhage (aSAH) patients treated within our institution over a 12-year period from 2011 to 2022. Methods The study comprised a retrospective analysis of prospectively collected data extracted from a hospital quality registry that we established in 2011, containing comprehensive information about all patients treated for aSAH. We included SAH patients within the institution's catchment area who underwent surgical or endovascular aneurysm repair. Exclusion criteria involved patients from external regions, those treated at other institutions, no aneurysm repair performed, or instances undergoing a combination of surgery and EVT. Pretreatment data encompassed the clinical condition at admission, comorbidity, radiological details, aneurysm characteristics, and duration between the bleed and aneurysm repair. Mortality was primary outcome measure; secondary outcome included modified Rankin Score after approximately six months. Results The study encompassed 1,171 patients (65% women and 35% men) undergoing aneurysm repair from 2011 to 2022. Admission data revealed 31.1% in Hunt-Hess grade 4–5. Surgical repair was performed in 573 (48.9%) patients, and EVT in 598 (51.1%) patients. Pretreatment information was comparable for both groups. Kaplan–Meier survival curves demonstrated lower mortality in the surgical than the EVT group (P = 0.023; Log-rank test) over the 12-year period. The 1-year, 5-year, and 10-year mortality rates were 12.4%, 19.5%, and 27.7% for the surgery group, and 18.7%, 25.2%, and 31.7% for the EVT group, respectively. Modified Rankin Score was worse for EVT. There was lower mortality in surgical than EVT groups in patients treated for anterior communicating artery (ACOM, n = 420) and posterior communicating artery (PCOM, n = 177) aneurysms. Shorter time to aneurysm repair and more extensive cerebrospinal fluid (CSF) drainage characterized the surgery group. Conclusions Mortality was lower in surgical patients. Plausible explanations are the maintenance of surgical skills and prompt reduction of intracranial pressure.