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Background Flow-diverter (FD) stents are increasingly being used in selected cases of aneurysmal subarachnoid hemorrhage (aSAH), but the clinical and resource implications of adding adjunctive coiling remain poorly defined. We compared outcomes of FD alone versus FD plus coiling in patients hospitalized with ruptured intracranial aneurysms.Methods Using the 2018-2022 National Inpatient Sample, we identified adult hospitalizations with a principal diagnosis of intracranial aneurysm and non-traumatic subarachnoid hemorrhage that underwent treatment with surgical clipping, endovascular coiling, or FD-based therapy. For the primary analysis, we restricted the cohort to FD-treated cases and compared FD only versus FD + coil. Outcomes included in-hospital mortality, discharge disposition, length of stay, and total hospital charges. Survey-weighted regression models adjusted for demographics, illness severity, socioeconomic factors, hospital characteristics, treatment era, and hospital aSAH volume.Results Among 5,665 weighted FD-treated aSAH hospitalizations, 5,495 (97.0%) underwent FD only and 170 (3.0%) underwent FD + coil. Patients treated with FD alone were older (67.9 ± 0.4 vs 60.3 ± 2.3 years; p < 0.001). Race distribution also differed (p < 0.001), with a greater proportion of White patients in the FD-only group (69.2% vs 60.6%) and a greater proportion of Hispanic patients in the FD+coil group (18.2% vs 10.5%). FD+coil cases were more frequently treated during 2020 (23.5% vs 15.0%; p = 0.027) and at urban teaching hospitals (91.2% vs 70.2%; p < 0.001). Sex, income quartile, APR-DRG severity, weekend admission, elective status, hospital volume, bed size, and region were similar between groups. Unadjusted in-hospital mortality was 21.3% for FD only versus 29.4% for FD+coil (p = 0.26). Routine home discharge among survivors was low in both groups, but numerically higher with FD alone (15.7% vs 8.3%; p = 0.33). After adjustment, FD alone was not associated with a significant mortality difference (OR 1.59, 95% CI 0.68-3.71, p = 0.28), and this remained consistent across progressively adjusted mortality models. However, FD alone was associated with lower odds of non-home discharge (OR 0.10, 95% CI 0.02-0.56, p = 0.009) and approximately 40% lower adjusted hospital charges (geometric mean ratio 0.60, 95% CI 0.47-0.78, p < 0.001), with no difference in length of stay.Conclusions In this national aSAH cohort, adjunctive coiling with FD was uncommon and did not improve survival. FD alone was associated with similar mortality, better discharge disposition, and substantially lower hospital charges.Disclosures K. Gupta: None. M. Karsy: None. D. Altschul: None.Abstract E-173 Table 1Key findings comparing flow diversion alone versus flow diversion plus coiling in aSAH