Between 2020 to 2023 a total of 307 patients were treated for intracranial aneurysms in our center. Among them, 94 were wide neck aneurysms located on the bifurcation sites. We included patients with ruptured WNB aneurysms who were treated by WEB or SAC alone within a week from the initial symptom. Patients with an 18th-month DSA follow-up were included in the study. Details of patient selection are provided in Fig. 1.

Age, gender, and other epidemiologic variables were obtained from electronic medical records. The initial status of subarachnoid hemorrhage (SAH) was assessed using the Hunt and Hess (H&H) scale. Aneurysms were described based on angiographic attributes such as dome-to-neck ratio and neck size. The duration of the procedure was defined as the time from arterial sheath placement to removal. This research adhered to the principles outlined in the Declaration of Helsinki. The institutional review boards approved our study with a waiver of written informed consent as deemed appropriate.

WEB and SAC were deployed in patients based on the treatment guidelines and under general anesthesia. Before the surgery, digital subtraction angiography (DSA) was conducted for all patients to ascertain the appropriate size of the devices. All the patients treated with SAC were administered peri procedural 5,000 IU heparin. Transfemoral access was obtained for all the patients. Guide sheath 7F (CATAPULTTM, Boston Scientific, USA) and Intermediate Catheter SOFIA 6 F (MicroVention, Aliso Viejo, CA) were employed for WEB embedding. The device was implanted with a suitable VIA microcatheter (Sequent Medical, Aliso Viejo, California, USA) for the size of the WEB device (MicroVention—Terumo, Tustin, CA, USA). In the SAC group, an intermediate catheter appropriate for SAC (MicroVention—Terumo, Tustin, CA, USA) was used, and the coiling catheter was either jailed or coiled with the deployed stents. The WEB group did not receive any antiplatelet medication, while the SAC group was given dual antiplatelet therapy with oral aspirin (80 mg/day) and clopidogrel (75 mg/day) after the procedure.

DSA was conducted immediately after device placement to evaluate immediate occlusion and in the 6th and 18th months. Radiological assessments during follow-up were classified according to the modified Raymond classification system (MRRC). Patients demonstrating major recanalization underwent reassessment for potential repeat endovascular interventions. Two experienced neurointerventionists were tasked with independently reviewing the initial and all subsequent DSA studies. Any discrepancies in interpretation were resolved through consensus, with consultation from a third neurointerventionist when necessary. The clinical status of patients was assessed using the modified Rankin scale (mRS) at the 3-month follow-up evaluation. A favorable mRS score was defined as 0-2.

All the statistical analyses were conducted by R-Studio 4.1.2. using TableOne package. Categorical variables are presented as counts and percentages and analyzed using the χ² or Fisher exact test. Shapiro-Wilk test was used to check the normality assumption. Continues variables presented by means±standard deviation (SD) and tested using independent t-test or Mann-Whitney U test. Significant results are defined as p value <0.05.

A total of 38 patients with 40 aneurysms were identified through searching our database. All patients had one aneurysm except for two patients with two aneurysms. SAC was used to treat 25 aneurysms (62.5%) in 23 patients, while WEB was utilized for 15 (37.5%) aneurysms in 15 patients (Table 1). The mean age was 58.62 and females comprised 40% of patients. Hypertension was reported in 65% of patients. Aneurysms were located in the middle cerebellar artery (35%), anterior communicating artery (32.5%), Basilar tip (12.5%), terminal part of the internal carotid (17.5%), and posterior inferior cerebellar artery (2.5%). All the patients presented with SAH and high-grade H&H scores (III and IV) were found in 40% without a significant difference between the two groups (p value=0.34). Aneurysm’s dome height (5.68±0.91 vs 6.96±1.43, p value: 0.002), width (4.58±0.77 vs 6.18±1.38, p value: <0.001), and neck (3.18±0.52 vs 4.35±0.98, p value: <0.001) were significantly higher in WEB. However, the aneurysmal dome-to-neck ratio did not differ significantly between the two groups (1.45±0.19 vs 1.43±0.17, p value: 0.79). Operational time was significantly lower in the WEB group (39.3 vs 66.2 minutes, p value: <0.001).

Immediate complete occlusion was recorded in 72% and 60% of SAC and WEB respectively without significant difference in occlusion rate (p value=0.64). DSA findings on the 18^th month revealed similar occlusion rates between the two groups (p value=0.42). Favorable mRS score at 3 months reached 100% and 93.3% of SAC and WEB patients respectively which was comparable between the two groups (p value=0.79). In addition, we did not find a significant difference in retreatment rate between the two groups (p value=1.0). Three patients in the SAC group retreated with additional flow diversion and SAC embolization was used in two primarily treated with WEB intervention. Comparable complication rate was found between the two groups (p value=0.39). Seven cases in each group showed post-operational vasospasm on magnetic resonance imaging (MRI) which was treated by intravascular injection of nimodipine and did not result in long-term sequel. The compressive effect of the device on the near branches occurred in one patient in each group which was solved by the device replacement (Table 2).