Application of a SQUIRE-compliant framework to improve patient management decision-making quality for microsurgery versus endovascular treatments in ruptured intracranial aneurysms

Rupture of intracranial aneurysm results in a potentially life-threatening subarachnoid hemorrhage (SAH) leading to a 45% mortality rate with only 30% returning to their normal life. Thus, the management decision is crucial. This study aimed to improve consistency, patient-centeredness, safety, and effectiveness of the decision-making for microsurgical or endovascular treatments of intracranial aneurysms (IAs) patients by appraisal of clinical, locational, and morphometric factors. We use the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines to guide the appraisal of 394 patients with 435 IAs for quality improvement of aSAH treatment decision making. Between January 2013 and December 2022, our team developed a flexible patient selection criterion for microsurgical or endovascular treatments of ruptured IAs. We depicted 312 (71.7%) and 123 (28.3%) anterior cerebral circulation IAs and posterior cerebral circulation IAs respectively. About 65.5%(n=285) were clipped whereas 34.5%(n=150) underwent coiling. Multiple factors (age, location, type, size, dome-to-neck ratio, WFNS grade at admission, and modified Rankin Scale “mRS” score) were found to influence the quality-improving decision-making for microsurgery or endovascular treatment of IAs. There was a statistically significant difference (p<0.001) between the aneurysmal morphometric factors for clinical decision of endovascular treatments (42% vs 58%) or microsurgical clipping (78.9% vs 21.1%) of the anterior and posterior cerebral circulation IAs respectively, with an Odds ratio 2.72; 95%CI [1.76 – 4.18]. Despite the management of IA's for many decades, reliable indicators for making decisions on microsurgical versus endovascular treatments for IA's are still debated.