Abstract 041: Comparative Analysis of Radiographic Vasospasm, Clinical Vasospasm, and Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: Clipping, Sole Coiling, and Stenting/Stent‐Assisted Coiling
Authors: Essibayi M. , Tos S. M. , Mortezaei A. , Vaishnav D. , Kasem R. Abo , Emara M. , Haranhalli N. , Altschul D. J. 
Published: January 2025

Introduction
Aneurysmal subarachnoid hemorrhage (SAH) is a critical condition with a high risk of complications, including radiographic vasospasm, clinical vasospasm, and delayed cerebral ischemia (DCI), which significantly affect patient outcomes. To manage these risks, various aneurysm treatments—clipping, sole coiling, and stenting/stent‐assisted coiling—are employed. Stenting, which often involves antiplatelet therapy, might reduce the risk of DCI. This study aims to compare the risks of radiographic vasospasm, clinical vasospasm, and DCI among these treatment modalities to provide insight into their relative effectiveness.

Methods
A systematic search across four electronic databases, with no language restrictions, was conducted to identify studies comparing clipping, sole coiling, and stenting/stent‐assisted coiling for aneurysmal SAH. Radiographic vasospasm is defined as arterial narrowing on imaging, clinical vasospasm as neurological deficits due to cerebral ischemia, and DCI as new, sustained neurological deficits not attributed to other causes. A subgroup meta‐analysis was performed, and risk ratios (RR) were calculated to compare these treatment modalities.

Results
Of the 966 studies screened, 394 underwent full‐text review, and 91 were included, comprising 15,174 patients: 7,454 in the clipping group, 10,105 in the coiling group, and 513 in the stenting group. The overall incidence of clinical vasospasm was 35% [95% CI: 29‐41%], with 36% [95% CI: 26‐46%] in clipping, 35% [95% CI: 27‐42%] in coiling, and 34% [95% CI: 3‐64%] in stenting (p = 0.96). Radiographic vasospasm occurred in 42% [95% CI: 30‐54%] overall, with 51% [95% CI: 32‐71%] in clipping, 37% [95% CI: 13‐60%] in coiling, and 34% [95% CI: 3‐64%] in stenting (p = 0.96). The incidence of DCI was 23% [95% CI: 17‐28%] overall, with 27% [95% CI: 19‐36%] in clipping, 17% [95% CI: 11‐24%] in coiling, and 23% [95% CI: 5‐42%] in stenting (p = 0.13). Comparative analyses revealed that the risk of radiographic vasospasm was significantly higher in the clipping group compared to the coiling group (RR: 1.13 [95% CI: 0.89‐1.44], p = 0.04). Similarly, the risk of DCI was also significantly higher in the clipping group than in the coiling group (RR: 1.30 [95% CI: 0.83‐2.05], p < 0.01). In contrast, the risk of clinical vasospasm was significantly lower in the stenting group compared to the coiling group (RR: 1.67 [95% CI: 0.45‐6.14], p = 0.01).

Conclusion
This analysis found that clipping is associated with a higher risk of radiographic vasospasm and DCI compared to coiling. In contrast, stenting demonstrated a lower risk of clinical vasospasm compared to coiling, likely due to the benefits of antiplatelet therapy. These findings underscore the need to consider specific complication risks when selecting treatment modalities for aneurysmal SAH. Further research is warranted to optimize treatment strategies.