Endovascular Management and Long-Term Outcomes of Aneurysmal Subarachnoid Hemorrhage Among a Large Cohort of Patients Managed at a Specialist Hospital in KwaZulu-Natal, South Africa from 2012 to 2021.

Abstract

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe stroke subtype with high morbidity and mortality, particularly in low- and middle-income countries. Endovascular treatment is underused in Africa due to resource constraints. This study evaluates clinical characteristics, radiological findings, treatment outcomes, and long-term follow-up of aSAH patients treated endovascularly at a South African quaternary hospital. A retrospective analysis of 445 aSAH patients treated endovascularly at the Inkosi Albert Luthuli Central Hospital (2012-2021) was conducted. Inclusion criteria were spontaneous aSAH confirmed by computed tomography/lumbar puncture and saccular aneurysm identified via computed tomography angiogram. Data on demographics, clinical presentation, World Federation of Neurological Societies and Modified Fisher grades, aneurysm characteristics, treatments, complications, and outcomes (modified Rankin Scale [mRS] and Raymond-Roy Occlusion Classification [RROC]) were analyzed. Logistic regression identified predictors of mortality, hydrocephalus, and vasospasm. Median age was 47 years (67% female, 75% Black African). Most (81%) had World Federation of Neurological Societies grades 1-3; 90% had anterior circulation aneurysms (median size 5.7 mm). Of 217 patients with known human immunodeficiency virus status, 48% were living with human immunodeficiency virus. Coil embolization (59%) and balloon-assisted coiling at 21% were common. At discharge, 73% achieved mRS 0-3 and 84% RROC 1. Long-term, 82% had mRS 0-3 and 90% RROC 1. Mortality was 8.3%. Complications included hydrocephalus (36%), vasospasm (22%), and meningitis (10%). Predictors of mortality included hydrocephalus and intraoperative complications; absence of intraventricular hemorrhage was protective. This study, the largest in an African cohort, confirms safety, efficacy, and durability of endovascular management of aSAH in resource-constrained settings, supporting its expansion in Africa.