Treatment Strategy and Prognosis in Ruptured Multiple Intracranial Aneurysms: Insights from a Multicenter Cohort Study

Objective: There is currently no clear consensus on the optimal treatment strategy for multiple intracranial aneurysms (MIAs). This study aims to systematically compare the clinical outcomes of one-stage treatment of all aneurysms versus treatment of only the responsible aneurysm in patients with ruptured MIAs. Methods: We included patients with ruptured MIAs who underwent surgical treatment in the Chinese Multicenter Cerebral Aneurysm Database (CMAD). 1:1 Propensity score matching (PSM) was applied to balance baseline differences between groups and to compare outcomes and complications between one-stage treatment of all aneurysms and treatment of the responsible aneurysm only. The association between treatment modality and in-hospital complications was assessed using a generalized estimating equation (GEE) model. Survival was analyzed using Kaplan–Meier curves, and Cox proportional hazards models were used to identify risk factors for mortality in patients with ruptured MIAs. Results: A total of 811 patients with ruptured MIAs were initially enrolled in this study. After PSM, 316 patients who underwent one-stage treatment were matched with 316 patients who received treatment for the responsible aneurysm only, resulting in 632 patients included in the final analysis. Although no statistically significant difference in mortality was observed between the groups, the survival curve trend favored one-stage treatment, with a lower 2-year mortality rate (11.2% vs. 16.2%; HR 1.368, 95% CI 0.920–2.032, P = 0.121). No significant differences were found between the groups in terms of functional outcomes or in-hospital complications. Multivariable Cox proportional hazards analysis identified age, previous stroke, and Hunt-Hess (HH) grade IV–V as independent risk factors for mortality. Endovascular treatment (EVT) was found to be a protective factor. Conclusion: In this cohort, one-stage treatment of ruptured MIAs appeared feasible and showed no evident excess risk compared with treating only the responsible aneurysm. Patient selection remains critical, and the identified mortality risk factors may provide useful guidance for clinical risk assessment and preventive strategies.