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Introduction/Purpose Ruptured cerebral aneurysms pose unique treatment challenges. In particular, wide-necked aneurysms may require either open microsurgical clipping or stent assistance to preserve the integrity of the coil mass, and permanent stenting requires dual anti-platelet therapy. Recent observational studies and meta-analyses support the use of intrasaccular flow disruptors (IFDs) in the treatment of selected, ruptured, wide-necked cerebral aneurysms. However, these series are relatively small. Furthermore, the comparative safety and efficacy of IFDs, microsurgical clipping, and stent-assisted coiling (SAC) for ruptured aneurysms is not yet well studied.Material and Methods The NeuroVascular Quality Initiative-Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry was queried for all treatments of ruptured aneurysms using IFD, SAC, or microsurgical clipping. Cases without reported discharge modified Rankin Scale (mRS) were excluded. The primary safety endpoint was poor functional status at discharge defined by mRS >2. A binary logistic regression analysis was employed to compare treatment methods, adjusting for confounders such as age, comorbidities, pre-operative mRS, and aneurysm location and size. A subgroup analysis of wide-necked aneurysms was also performed.Results Of all eligible cases, we identified 83 treatments with IFD, 427 with microsurgical clipping, and 48 with SAC. The microsurgical clipping cohort was the youngest (53±13 years) and had the highest proportion of patients without comorbid conditions (43%). Intraoperative complications were highest among SAC (23%), followed by microsurgical clipping (12.9%), and IFD (6%; p=0.020). SAC had the highest rate of poor discharge mRS (79%), followed by microsurgical clipping (63%), and IFD (60%; p=0.064). Univariate regression revealed that increasing age, preoperative mRS, aneurysm neck size, and presence of any comorbidity were associated with poor functional outcomes at discharge. A multivariate regression analysis was performed comparing the treatment modalities, adjusting for age, preoperative mRS, aneurysm dome and neck size, aneurysm location, and comorbidities. Compared with IFD, microsurgical clipping and SAC had significantly higher adjusted odds of poor functional outcomes (OR 3.26, 95% CI: 1.47-7.22, p=0.004; OR 4.29, 95% CI: 1.33-13.81, p=0.015). At last clinical follow up, patients treated with IFD had the lowest rate of poor functional status (15%) followed by microsurgical clipping (24%) and SAC (44%, p=0.047). Of all cases, 194/558 (35%) were wide-necked defined as neck ≥ 4 mm or dome-to-neck ratio ≤ 2. These results remained consistent within the wide-necked cohort.Conclusion In the treatment of ruptured aneurysms, IFDs demonstrated highly favorable adjusted odds of good functional outcome at discharge compared with microsurgical clipping and SAC. This finding was maintained through last clinical follow up. Additional studies are needed to compare long term efficacy and safety outcomes between treatment methods.Disclosures S. Shah: None. D. Hallan: None. V. Padmanaban: None. S.A. Ansari: None. D.L. Dornbos III: None. S. Pahwa: None. D. Sahlein: None. J. Tejada: None. D. Wilkinson: None. S. Simon: None. K. Cockroft: None. E. Church: None.