Early versus Delayed Microsurgical Clipping of Additional Unruptured Aneurysms in Patients with Aneurysmal Subarachnoid Hemorrhage.

Background: The optimal timing for the surgical treatment of additional unruptured aneurysms in patients with multiple aneurysms and aneurysmal subarachnoid hemorrhage (aSAH) is unknown. Therefore, we analyzed the results of early versus delayed microsurgical treatment of unruptured aneurysms when multiple aneurysms were present in the setting of aSAH.

Methods: The medical records from a consecutive, single-surgeon, 19-year experience of all patients with aSAH and additional unruptured aneurysms treated with a second surgery were reviewed retrospectively. Early treatment was defined as treatment within 30 days and delayed treatment as treatment more than 30 days after the initial surgery for aSAH.

Results: A total of 85 patients with aSAH and multiple aneurysms were identified. Early (n = 55; 65%) or delayed (n = 30; 35%) clipping was performed for additional unruptured aneurysms. Intraoperative rupture (P = 0.028), higher Fisher grade (P = 0.046), multiple additional unruptured aneurysms (P = 0.04), and large aneurysm size of either the ruptured aneurysm (P = 0.034) or unruptured aneurysm (P = 0.022) were significant factors favoring early treatment. Significant differences were not observed with respect to outcome (modified Rankin scale), unfavorable modified Rankin scale changes between the first surgery and last follow-up, aneurysm occlusion, and shunt-dependent hydrocephalus. No ruptures of untreated aneurysms during the follow-up course were observed.

Conclusions: Both early and delayed surgical treatment of unruptured aneurysms in the setting of aSAH are safe. Factors prompting earlier intervention might include multiple additional aneurysms, larger aneurysms, and intraoperative aneurysm rupture, which could suggest a destabilized arterial wall. Delayed treatment is advisable for patients with a poor clinical presentation, greater underlying brain injury, and a swollen brain requiring decompressive craniectomy to allow time for recovery.