The role of microsurgery for poor-grade aneurysmal subarachnoid hemorrhages in the endovascular era

Background Poor-grade aneurysmal subarachnoid hemorrhage (PGASAH) is associated with high mortality and morbidity regardless of treatment. Herein, we re-evaluate the safety and efficacy of microsurgical treatment for managing PGASAH patients in the current endovascular era. Methods We retrospectively reviewed 141 consecutive patient records in a single institution who underwent microsurgical ( n = 80) or endovascular ( n = 61) treatment for PGASAH. Results Baseline characteristics were similar, except for more intracerebral hematomas (46.3% vs 24.6%, p = 0.009), fewer intraventricular hemorrhages (26.3% vs 59%, p < 0.001), and fewer posterior circulation aneurysms (5.1% vs 44.3%, p < 0.001) in the microsurgery group. Decompressive craniectomy (58.5% vs 24.6%, p < 0.001) and shunt-dependent hydrocephalus (63.7% vs 41%, p = 0.01) were more common for microsurgery, while procedural ischemic complications were less common (5% vs 24.6%, p = 0.001). Both early (12.5% vs 32.8%, p = 0.006) and late mortality rates (22.5% vs 39.3%, p = 0.041) were lower for microsurgery, and favorable 12-month outcomes (modified Rankin scale = 0–2) were better (62.5% vs 42.6%, p = 0.026). Multivariate analysis revealed that advanced age, neurological grade, modified Fisher grade, larger aneurysm size, rebleeding, and cerebral infarctions were independent predictors of poor outcome. Microsurgery fared marginally better than endovascular treatment (OR: 2.630, 95% CI: [0.991–6.981], p = 0.052). Conclusions Timely and efficient treatment, either via open microsurgery or endovascular surgery, provided favorable outcomes for over half of PGASAH patients in this series. Therefore, early treatment should be offered to all PGASAH patients regardless of clinical and/or radiological factors. Microsurgery remains an effective treatment modality for selected PGASAH patients in the endovascular era.