Endovascular management and long-term outcomes of aneurysmal subarachnoid haemorrhage among a large cohort of patients managed at a specialist hospital in KwaZulu-Natal, South Africa from 2012 to 2021

Aneurysmal subarachnoid haemorrhage (aSAH) is a severe stroke subtype with high morbidity and mortality, particularly in low- and middle-income countries. Endovascular treatment is underutilized 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 Inkosi Albert Luthuli Central Hospital (2012-2021) was conducted. Inclusion criteria were spontaneous aSAH confirmed by CT/lumbar puncture and saccular aneurysm identified via CT angiogram. Data on demographics, clinical presentation, WFNS and Modified Fisher grades, aneurysm characteristics, treatments, complications, and outcomes (modified Rankin Score mRS, 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 WFNS grades 1-3; 90% had anterior circulation aneurysms (median size 5.7 mm). Of 217 patients with known HIV status, 48% were living with HIV. Coil embolization (59%) and balloon-assisted coiling (BAC) at 21% were common. At discharge, 73% achieved mRS 0-3, 84% RROC 1. Long-term, 82% had mRS 0-3, 90% RROC 1. Mortality was 8.3%. Complications included hydrocephalus (36%), vasospasm (22%), and meningitis (10%). Predictors of mortality included hydrocephalus and intra-operative complications; absence of intraventricular haemorrhage 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.