Early Flow-Diverter Implantation in Ruptured Intracranial Aneurysms: Safety and Outcomes in a Resource-Limited Setting

PURPOSE: Flow-diverting stents (FDs) provide a reconstructive option for complex ruptured aneurysms, including blister-like, fusiform, and small saccular lesions. Their use in acute subarachnoid hemorrhage (SAH) is limited by dual antiplatelet therapy (DAPT) and hemorrhagic risk, with scarce data from resource-limited settings. MATERIALS AND METHODS: We retrospectively reviewed 26 patients with ruptured intracranial aneurysms treated with FDs within 7 days of ictus at a single tertiary center (July 2021-June 2025). Exclusion criteria included adjunctive coiling/clipping, FD placement >7 days, and aneurysms >5 mm. Outcomes included 90-day functional status (modified Rankin Scale [mRS]), angiographic occlusion (O'Kelly-Marotta grading), and procedural complications. RESULTS: Mean age was 47.3±12.1 years; 61.5% were male. Aneurysm types were saccular (42.3%), blister-like (34.6%), and fusiform/dissecting (23.1%). FD placement occurred at a mean of 3.9±1.8 days post-ictus, with 100% technical success and no intraprocedural complications. Favorable functional outcome (mRS 0-2) was achieved in 84.6%, and mortality was 15.4%, all secondary to SAH. Complete angiographic occlusion was observed in all 21 patients with imaging follow-up. Procedure-related ischemic complications occurred in 11.5%, mostly transient or minimally disabling, with 1 disabling infarct (mRS 3); no hemorrhagic events related to DAPT or aneurysm rebleeds were observed. CONCLUSION: Early FD implantation in carefully selected ruptured aneurysms, including small saccular and morphologically complex lesions can achieve high functional recovery and complete angiographic occlusion, even in a resource-limited environment. Ideal case selection and standardized DAPT and hemodynamic protocols are critical. These findings support broader use in challenging aneurysms, but larger prospective studies are warranted to validate outcomes and refine management strategies.