Inflammation, coagulation, and nutritional reserves refine 90-day prognostic stratification after ruptured intracranial aneurysm repair

Background Ruptured intracranial aneurysm is a major cause of neurological disability. Existing prognostic models primarily rely on neurological and radiological severity and may overlook systemic biological alterations. Objective To evaluate whether integrating systemic immune-inflammation index (SII), D-dimer, and prognostic nutritional index (PNI) with clinical-radiological factors improves prediction of 90-day unfavorable neurological recovery after aneurysm repair. Methods This single-center retrospective cohort study included 209 patients with aneurysmal subarachnoid hemorrhage undergoing clipping or coiling between January 2023 and December 2025. The primary outcome was unfavorable 90-day functional recovery (modified Rankin Scale 3–6). Admission biomarkers were analyzed using multivariable logistic regression. An admission model and an updated in-hospital model incorporating delayed cerebral ischemia (DCI) were developed and evaluated using discrimination, calibration, decision curve analysis, and bootstrap validation. Results Among 209 patients, 66 (31.6%) had unfavorable outcomes. Independent predictors included Hunt–Hess grade IV–V (aOR 3.85, 95% CI 1.84–8.06), modified Fisher grade 3–4 (aOR 2.76, 95% CI 1.28–5.95), acute hydrocephalus (aOR 2.62, 95% CI 1.25–5.48), higher SII (aOR 1.32 per 500-unit increase), higher D-dimer (aOR 1.22 per 1 mg/L increase), and lower PNI (aOR 0.68 per 5-point increase). The admission model achieved an AUC of 0.82 (95% CI 0.76–0.88), while the updated model incorporating DCI improved the AUC to 0.86 (95% CI 0.80–0.91), with an optimism-corrected AUC of 0.83 after bootstrap validation. Conclusion An integrated model combining inflammatory, coagulation, nutritional, and clinical-radiological factors improved risk stratification after ruptured intracranial aneurysm repair. Incorporation of DCI provided additional prognostic value, although external validation is needed.