Treatment of patients with aneurysmal subarachnoid hemorrhage and multiple aneurysms: Concurrent versus delayed treatment.

Objective: 8-30 % of patients who present with aneurysmal subarachnoid hemorrhage (aSAH) have multiple intracranial aneurysms (MIA). Although prompt treatment to secure ruptured aneurysms (RA) is standard of care, there is no clear consensus regarding whether incidental unruptured aneurysms (UA) should be treated during the same procedural time as the RA. This study aims to examine the effect of treatment of UA during the same procedural time as treatment for the RA (concurrent treatment) versus delaying the treatment of an UA after discharging the patient (delayed treatment).

Methods: This is a retrospective review of the medical records of patients with the diagnosis of aSAH and MIA admitted to a single neurocritical care unit between 2013 and 2021, and who underwent treatment of at least 1 aneurysm during the index hospitalization. Data was divided in 2 groups: concurrent treatment (2 or more aneurysms treated), and delayed treatment (1 aneurysm treated). Clinical and radiological data including demographic characteristics, modified Fisher Scale (mFS), treatment modality (clipping or endovascular), ventriculoperitoneal shunt (VPS) rates, surgical/procedural complications, delayed cerebral ischemia (DCI), length of stay (LOS), modified Rankin Score (mRS) and type of insurance of the patients during the hospitalization were collected.

Results: We identified 109 patients with aSAH and MIA, who fit criteria. The median age was 58 (48-67) years old. 91 were female (83.5 %). A total of 287 aneurysms were found, 109 were ruptured. 64 patients underwent treatment of a single aneurysm (delayed treatment group), and 45 patients underwent treatment of 2 or more aneurysms (concurrent treatment group). mFS were similar in both groups (p=.56). Clipping (52.3 %) was the treatment modality most frequently used. No significant differences in surgical/procedural complications (p=.54) or VPS (p=.91) rates were seen among the 2 groups. No significant differences in delayed cerebral ischemia rates were seen (p=.85) There were no significant differences between the mRS at discharge (mRS 0-3 v 4-6 (p=.78)), LOS in the ICU (12 vs 13 (p=.58) days) and LOS in the hospital (16 vs 14.5 (p=.95) days) between the delayed and concurrent treatment groups respectively.

Conclusions: No difference in functional status at discharge was observed between delayed treatment versus concurrent treatment. Treatment of most or all surgically amenable aneurysms, at the time when the RA is being treated, does not increase the risk of DCI or poor outcomes at discharge.