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Introduction/Purpose Delayed cerebral ischemia (DCI) and vasospasm remain leading causes of morbidity following aneurysmal subarachnoid hemorrhage (aSAH). Repeat digital subtraction angiography is often performed during hospitalization for evaluation and treatment of radiographic vasospasm and clinical DCI. A known consequence of frequent DSA is a cumulative risk of stroke as well as silent ischemic events demarcated by restricted diffusion on diffusion weighted imaging (DWI). However, their relationship between DSA exposure, DWI lesion burden, and outcomes following aSAH remains unclear. We sought to evaluate whether DSA burden correlates with DWI lesion burden, and whether DWI lesion burden affects aSAH outcomes.Methods and Methods Consecutive patients with spontaneous aSAH at a single tertiary referral center (2015-2025) were retrospectively reviewed. Traumatic or non-aneurysmal etiologies were excluded. Analyses were restricted to patients who underwent magnetic resonance imaging (MRI) during index hospitalization. DWI lesion burden was quantified as the number of discrete hyperintense lesions seen on DWI sequences on MRI. DSA burden was defined as the number of angiographic procedures performed prior to MRI during the index hospitalization. We assessed for the occurrence of DCI, vasospasm, and modified Rankin Scale (mRS) at discharge. Univariate logistic or linear regression analyses were performed to assess independent associations between continuous predictors and binary outcomes, or continuous predictors and continuous outcomes, respectively. Covariates included age, sex, DSA count, DWI burden, vasospasm, or DCI occurrence.Results Of 1,062 patients screened, 133 (50 males, 83 females) underwent inpatient MRI during the index hospitalization. DCI occurred in 42.1%. Mean age of DCI patients was 54.4 years versus 57.4 in non-DCI patients (p=0.26). Median number of DSAs was significantly higher in the DCI cohort compared to the non-DCI cohort (median 2 vs 1, respectively; p=0.015). DWI lesion burden did not significantly differ between groups (p=0.55). Each additional DSA was associated with approximately two-fold greater number of DWI lesions (univariate OR=2.12, p=0.008; multivariate OR=1.92, p=0.04). DWI lesion burden was not associated with DCI, vasospasm, or discharge mRS. Vasospasm independently predicted worse discharge mRS (greater than or equal to 3) irrespective of severity (univariate OR=5.81, p=0.0001; multivariate OR=6.22, p=0.003).Conclusion Increasing number of DSAs is associated with more DWI lesions on MRI, likely reflective of cumulative procedural burden. However, DWI lesion burden, did not correlate with functional outcomes, thus, clinicians should prioritize treating vasospasm and DCI without worrying about additional risk of poor clinical outcomes related to increased DWI lesion burden.Disclosures H. Granberg: None. A. Helal: None. M. Salem: None. Y. Zhou: None. R. Moseley: None. D. Assatory: None. C. Roark: None. J. Seinfeld: None. D. Case: None.Abstract E-200 Figure 1Boxplot illustrating association between diffusion weighted imaging lesion burden and DCI occurrence in patients who underwent MRIAbstract E-200 Figure 22A-2D: Axial MRI without contrast illustrating example DWI series (figure 2A/2C) and corresponding apparent diffusion imaging series (figure 2B/2D). Red arrows are pointing to hyperintense lesions on DWI series (figures 2A/2C), with the same lesions appearing hypointense on apparent diffusion series (figures 2B/2D)