LAUSR

BACKGROUND Intracranial bypass to treat ruptured aneurysms has been well described in the literature but is largely deferred in patients with higher Hunt & Hess (H&H) grades due to complexity and length of surgery, risk of inducing vasospasm, and poor prognosis. However, there is a paucity of data and no direct comparison to more traditional open surgical techniques. This study investigated outcomes in patients with H&H grade 3-5 aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for standalone endovascular treatment managed with bypass compared with direct surgical clipping. METHODS A prospective database of patients treated for aSAH with H&H grade 3-5 between 2013-2018 was retrospectively analyzed. Complications and functional status at discharge and latest follow-up were compared between patients that underwent bypass surgery versus direct clipping. RESULTS Twenty-three patients underwent revascularization and 60 underwent clipping alone. There were no significant differences in all-cause 30-day mortality (15 versus 16%; p=0.97) or Glasgow Outcome Scale and modified Rankin Scale at discharge or median eight-month follow-up (p>0.67). There was a higher overall stroke rate with revascularization (p=0.004), specifically endovascular treatment-related stroke (p=0.049), with no difference in surgical (p=0.47) or vasospasm-related stroke (p=0.53). There were no differences in overall complications, medical complications, seizures, re-ruptures, hydrocephalus, or perioperative death (p>0.05). CONCLUSIONS Bypass is a viable option for patients presenting with higher H&H grade aSAH deemed unfavorable for standalone endovascular therapy. Despite obvious differences in aneurysm complexity and a higher risk of stroke, functional outcomes with revascularization can be comparable to clipping in this high-risk patient cohort.