KUMJ | VOL. 24 | NO. 2 | ISSUE 95 | APRIL - JUNE, 2026

Clinical Outcomes and Systemic Barriers to Endovascular Treatment for Aneurysmal Subarachnoid Hemorrhage in Nepal: A Single Center Prospective Observational Study
Shrestha B, Shrestha A, Bhusal J, Shrestha J, Phuyal S

Abstract:
Background Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurovascular emergency with significant mortality and morbidity. While endovascular treatment has demonstrated superior outcomes in various landmark international trials, its implementation in low- and middle-income countries like Nepal remains a struggle due to socioeconomic and infrastructural barriers. Objective To evaluate the feasibility, safety, clinical outcomes, and descriptive cost assessment of endovascular treatment for aSAH in a resource-limited setting. Method Nineteen patients with angiographically confirmed aSAH who underwent endovascular treatment from January 2024 to December 2024 were included. Clinical outcomes were assessed using the modified Rankin Scale at discharge and three months, while angiographic outcomes were evaluated using the Raymond- Roy Occlusion Classification (RROC) and O’Kelly - Marotta Scale at the end of the procedure and at six months. Cost analysis was performed to determine the economic burden on patients and families. Result The mean age of patients was 57.63 ± 10.98 years, with a female predominance (73.70%). The anterior communicating artery was the most common aneurysm location (47.40%), and 15.78% of patients had multifocal aneurysms. Technical success was achieved in all cases (100%). Immediate post-procedural angiography demonstrated complete occlusion (RROC I) in 14/19 cases (73.68%), while RROC II was observed in 3/19 cases (15.78%). Two cases treated with flow diversion demonstrated O’Kelly - Marotta grade B3 occlusion. Favorable functional outcome (modified Rankin Scale ≤ 2) at discharge was achieved in 15/19 patients (78.94%). In-hospital mortality was 5.26%, with no procedure-related deaths. The majority of patients (84.20%) belonged to the upper-middle socioeconomic class according to the modified Kuppuswamy index (2023). The mean total treatment cost was Nepalese Rupees (NRs.) 7,48,294.37 ± 211,242.07, with device and consumable expenses accounting for 58.61% ± 14.12 of total costs. National health insurance provided partial reimbursement with a median coverage of NRs. 70,000 (IQR: 78,023.47; range: NRs.0 – 1,00,000). Conclusion Endovascular treatment for ruptured cerebral aneurysms appears feasible and safe in a semi-urban Nepalese setting when supported by structured training and strategic resource management.
Keyword : Aneurysm, Cost and cost analysis, Endovascular procedures, Subarachnoid hemorrhage, Treatment outcome