LAUSR

INTRODUCTION 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 results from early versus delayed microsurgical treatment of unruptured aneurysms when multiple aneurysms are present in the setting of aSAH. METHODS Charts 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 <1 month and delayed treatment as >1 month after the initial surgery for the aSAH. RESULTS In total, 85 patients with aSAH and multiple aneurysms were identified and 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 (mRS), unfavorable mRS change between first surgery and last follow-up, aneurysm occlusion, and shunt-dependent hydrocephalus. No ruptures of untreated aneurysms during the course of follow-up were observed. CONCLUSIONS Both early and delayed surgical treatment of unruptured aneurysms in the setting of aSAH is safe. Factors prompting earlier intervention may include multiple additional aneurysms, larger aneurysms, and intraoperative aneurysm rupture, which may suggest destabilized arterial wall. Delayed treatment is advisable for patients with poor clinical presentations, more underlying brain injury, and swollen brains requiring decompressive craniectomy, thereby allowing time for recovery.