Endovascular Management of Aneurysmal Subarachnoid Hemorrhage in People Living With HIV: Comparable Outcomes in a High-Prevalence Setting

BACKGROUND AND OBJECTIVES: The relationship between aneurysmal subarachnoid hemorrhage (aSAH) and HIV is poorly understood, particularly regarding endovascular outcomes in high-prevalence regions, where current guidelines favor endovascular management for ruptured saccular aneurysms amenable to both coiling and clipping, although some suggest surgical clipping may be preferable for people living with HIV (PLWH). This research investigates and contrasts the clinical features, laboratory results, imaging characteristics, therapeutic approaches, associated complications, as well as short-term and long-term clinical and radiological results of aSAH managed endovascularly in PLWH vs HIV-negative patients at Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, South Africa, over a 10-year period. METHODS: Retrospective (2012-2016) and prospective (2017-2021) cohort study of patients with aSAH secondary to saccular aneurysms treated endovascularly. Data encompassed demographics, clinical presentation, laboratory and radiological findings, treatment, complications, clinical outcomes, and occlusion rates. Univariate and multivariate logistic regressions, adjusted for age, sex, and residence-assessed HIV associations. Multiple imputation addressed missing HIV data, analyzed in R (v4.4.1). RESULTS: Of 445 patients, 105 were PLWH, 112 HIV-negative, and 228 unknown (mostly retrospective). No significant differences in age, comorbidities, symptoms, World Federation of Neurological Surgeons grade, referral hospital, residence, timelines, intensive care unit stay, hospital length, Fisher grade, aneurysm characteristics, hydrocephalus, shunt dependency, endovascular treatment modalities, vasospasm, or meningitis. Aneurysm location differed: Anterior communicating artery aneurysms were more common in PLWH, posterior communicating in HIV-negative. Good outcomes (modified Rankin Score 0-3) occurred in 81% PLWH vs 79% HIV-negative. Complete occlusion (Raymond-Roy 1) was 88% vs 81% at discharge in PLWH vs HIV-negative, respectively, with similar long-term results. CONCLUSION: Endovascular management of aSAH from saccular aneurysms in PLWH yields outcomes comparable with HIV-negative patients, supporting standard protocols regardless of HIV status.