{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T09:08:48Z","timestamp":1779700128359,"version":"3.53.1"},"reference-count":29,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T00:00:00Z","timestamp":1778803200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Neurology International"],"abstract":"<jats:p>Background\/Objectives: The optimal upfront modality selection for real-world aneurysmal subarachnoid hemorrhage (aSAH) remains uncertain. We evaluated outcomes after an institutional change from an endovascular treatment (EVT)-first default to a modality-neutral individualized pathway. Methods: This single-center retrospective before-and-after cohort study included consecutive patients with aSAH who underwent aneurysm securing during two fixed time periods (pre-change: 1 May 2023 to 31 July 2024; post-change: 1 August 2024 to 31 October 2025). The primary outcome was a favorable 90-day modified Rankin Scale (mRS) score of 0\u20132. The primary analysis used Firth penalized logistic regression adjusted for age, pre-morbid mRS \u2265 2, and World Federation of Neurosurgical Societies grade IV\u2013V. Conventional logistic regression and ordinal mRS shift analysis were performed as sensitivity analyses. Results: A total of 104 patients were included (pre-change, n = 48; post-change, n = 56). EVT decreased from 79.2% to 37.5%, and microsurgery increased from 20.8% to 62.5% (p &lt; 0.001). Favorable outcomes occurred in 25\/48 patients (52.1%) in the pre-change period and 36\/56 patients (64.3%) in the post-change period (p = 0.235). In adjusted analyses, the post-change period was associated with favorable outcome (aOR 3.82; 95% CI, 1.31\u201312.79; p = 0.009), consistent with the sensitivity analysis (aOR, 4.41; 95% CI, 1.43\u201315.95; p = 0.009). Shift analysis also favored the post-change period (adjusted common OR, 2.36; 95% CI, 1.15\u20134.91; p = 0.021). Secondary outcomes and procedure-related complications were similar between the two periods. Conclusions: A shift from an EVT-first default to a modality-neutral individualized pathway was associated with more favorable adjusted 90-day functional outcomes. Multicenter confirmation is warranted.<\/jats:p>","DOI":"10.3390\/neurolint18050093","type":"journal-article","created":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T08:06:26Z","timestamp":1779696386000},"page":"93","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Individualized Upfront Treatment Selection for Aneurysmal Subarachnoid Hemorrhage and Functional Outcomes: A Single-Center Retrospective Before-and-After Cohort Study"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-9086-1302","authenticated-orcid":false,"given":"Atsushi","family":"Nakayashiki","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka 020-0066, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kunihiko","family":"Umezawa","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka 020-0066, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yasuo","family":"Nishijima","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka 020-0066, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryutaro","family":"Suzuki","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka 020-0066, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michiko","family":"Yokosawa","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka 020-0066, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hidenori","family":"Endo","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1267","DOI":"10.1016\/S0140-6736(02)11314-6","article-title":"International Subarachnoid Aneurysm Trial (ISAT) of Neurosurgical Clipping versus Endovascular Coiling in 2143 Patients with Ruptured Intracranial Aneurysms: A Randomised Trial","volume":"360","author":"Molyneux","year":"2002","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"809","DOI":"10.1016\/S0140-6736(05)67214-5","article-title":"International Subarachnoid Aneurysm Trial (ISAT) of Neurosurgical Clipping versus Endovascular Coiling in 2143 Patients with Ruptured Intracranial Aneurysms: A Randomised Comparison of Effects on Survival, Dependency, Seizures, Rebleeding, Subgroups, and Aneurysm Occlusion","volume":"366","author":"Molyneux","year":"2005","journal-title":"Lancet"},{"key":"ref_3","first-page":"e314","article-title":"2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association\/American Stroke Association","volume":"54","author":"Hoh","year":"2023","journal-title":"Stroke"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"646","DOI":"10.1007\/s00134-024-07387-7","article-title":"Contemporary Management of Aneurysmal Subarachnoid Haemorrhage. An Update for the Intensivist","volume":"50","author":"Robba","year":"2024","journal-title":"Intensive Care Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"98","DOI":"10.3171\/2024.4.JNS232191","article-title":"REACT: A Randomized Trial to Assess the Efficacy and Safety of Clazosentan for Preventing Clinical Deterioration Due to Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage","volume":"142","author":"Mayer","year":"2025","journal-title":"J. Neurosurg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1186\/1745-6215-14-156","article-title":"International Subarachnoid Aneurysm Trial\u2013ISAT Part II: Study Protocol for a Randomized Controlled Trial","volume":"14","author":"Darsaut","year":"2013","journal-title":"Trials"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e065903","DOI":"10.1136\/bmjopen-2022-065903","article-title":"Endovascular versus Neurosurgical Aneurysm Treatment: Study Protocol for the Development and Validation of a Clinical Prediction Tool for Individualised Decision Making","volume":"12","author":"Roozenbeek","year":"2022","journal-title":"BMJ Open"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"w13934","DOI":"10.4414\/smw.2014.13934","article-title":"Management of Aneurysmal Subarachnoid Haemorrhage","volume":"144","author":"Schatlo","year":"2014","journal-title":"Swiss Med. Wkly."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1177\/1591019915617320","article-title":"Management of Aneurysmal Subarachnoid Haemorrhage with Intracerebral Hematoma: Is There an Indication for Coiling First? Study of 44 Cases","volume":"22","author":"Salaud","year":"2016","journal-title":"Interv. Neuroradiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1016\/j.wneu.2012.03.008","article-title":"Outcomes for Clip Ligation and Hematoma Evacuation Associated with 102 Patients with Ruptured Middle Cerebral Artery Aneurysms","volume":"80","author":"Bohnstedt","year":"2013","journal-title":"World Neurosurg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"141","DOI":"10.5797\/jnet.oa.2021-0034","article-title":"Coiling for Ruptured Aneurysms in the Vasospasm Period: Safety and Efficacy Based on a Propensity Score Analysis","volume":"16","author":"Koiso","year":"2022","journal-title":"J. Neuroendovasc. Ther."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Li, W., Zhu, W., Sun, X., Liu, J., Wang, Y., Wang, K., Zhang, Y., Yang, X., and Zhang, Y. (2021). Retreatment With Flow Diverters and Coiling for Recurrent Aneurysms After Initial Endovascular Treatment: A Propensity Score-Matched Comparative Analysis. Front. Neurol., 12.","DOI":"10.3389\/fneur.2021.625652"},{"key":"ref_13","unstructured":"National Institute for Health and Care Excellence (2022). Subarachnoid Haemorrhage Caused by a Ruptured Aneurysm: Diagnosis and Management, National Institute for Health and Care Excellence (NICE). Available online: https:\/\/www.nice.org.uk\/guidance\/NG228."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"575","DOI":"10.2176\/nmc.ra.2017-0057","article-title":"Aneurysmal Subarachnoid Hemorrhage in the Elderly over Age 75: A Systematic Review","volume":"57","author":"Ohkuma","year":"2017","journal-title":"Neurol. Med. Chir."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2883","DOI":"10.1161\/STROKEAHA.118.022869","article-title":"Survival and Outcome After Poor-Grade Aneurysmal Subarachnoid Hemorrhage in Elderly Patients","volume":"49","author":"Goldberg","year":"2018","journal-title":"Stroke"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1513","DOI":"10.3174\/ajnr.A1633","article-title":"Difficult Aneurysms for Endovascular Treatment: Overwide or Undertall?","volume":"30","author":"Brinjikji","year":"2009","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_17","first-page":"513","article-title":"Endovascular Treatment of Middle Cerebral Artery Aneurysms with Electrolytically Detachable Coils","volume":"27","author":"Doerfler","year":"2006","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"221","DOI":"10.7461\/jcen.2021.E2021.03.001","article-title":"Endovascular Treatment of Residual or Recurrent Intracranial Aneurysms after Surgical Clipping","volume":"23","author":"Trivelato","year":"2021","journal-title":"J. Cerebrovasc. Endovasc. Neurosurg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1136\/jnis-2023-020675","article-title":"Decoding the Data: A Comment on the American Heart Association\/American Stroke Association (AHA\/ASA) 2023 Guideline for the Management of Patients with Aneurysmal Subarachnoid Hemorrhage","volume":"15","author":"Fraser","year":"2023","journal-title":"J. Neurointerv. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2391","DOI":"10.1161\/STROKEAHA.110.589275","article-title":"Definition of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage as an Outcome Event in Clinical Trials and Observational Studies: Proposal of a Multidisciplinary Research Group","volume":"41","author":"Vergouwen","year":"2010","journal-title":"Stroke"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.clineuro.2014.06.030","article-title":"Protective Effect of External Ventricular Drainage on Cerebral Vasospasm. A Retrospective Study on Aneurysmal SAH Treated Endovascularly","volume":"124","author":"Scerrati","year":"2014","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"833","DOI":"10.1001\/jamaneurol.2023.1792","article-title":"Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial","volume":"80","author":"Wolf","year":"2023","journal-title":"JAMA Neurol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1707","DOI":"10.3171\/2022.2.JNS212914","article-title":"Effects of Clazosentan on Cerebral Vasospasm-Related Morbidity and All-Cause Mortality after Aneurysmal Subarachnoid Hemorrhage: Two Randomized Phase 3 Trials in Japanese Patients","volume":"137","author":"Endo","year":"2022","journal-title":"J. Neurosurg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1093\/biomet\/80.1.27","article-title":"Bias Reduction of Maximum Likelihood Estimates","volume":"80","author":"Firth","year":"1993","journal-title":"Biometrika"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2409","DOI":"10.1002\/sim.1047","article-title":"A Solution to the Problem of Separation in Logistic Regression","volume":"21","author":"Heinze","year":"2002","journal-title":"Stat. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1080\/00273171.2011.568786","article-title":"An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies","volume":"46","author":"Austin","year":"2011","journal-title":"Multivar. Behav. Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"3083","DOI":"10.1002\/sim.3697","article-title":"Balance Diagnostics for Comparing the Distribution of Baseline Covariates between Treatment Groups in Propensity-Score Matched Samples","volume":"28","author":"Austin","year":"2009","journal-title":"Stat. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.1016\/S0895-4356(96)00236-3","article-title":"A Simulation Study of the Number of Events per Variable in Logistic Regression Analysis","volume":"49","author":"Peduzzi","year":"1996","journal-title":"J. Clin. Epidemiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"710","DOI":"10.1093\/aje\/kwk052","article-title":"Relaxing the Rule of Ten Events per Variable in Logistic and Cox Regression","volume":"165","author":"Vittinghoff","year":"2007","journal-title":"Am. J. Epidemiol."}],"container-title":["Neurology International"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2035-8377\/18\/5\/93\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T08:55:38Z","timestamp":1779699338000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2035-8377\/18\/5\/93"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,15]]},"references-count":29,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["neurolint18050093"],"URL":"https:\/\/doi.org\/10.3390\/neurolint18050093","relation":{},"ISSN":["2035-8377"],"issn-type":[{"value":"2035-8377","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,15]]}}}