Problems in the treatment of ruptured intracranial aneurysms in the acute stage

Abstract

The authors summarized 368 cases of ruptured anterior communicating (ACo), internal carotid (IC), and middle cerebral (MC) aneurysms (AN) who were admitted within seven days of their last attack during a period from 1976 to 1982. They were managed according to established principles of treatment. Radical operations for cerebral aneurysm were done as early as possible except in cases with vasospasm, irreversible brain-stem damage, posterior circulation aneurysm, severe systemic complication, age greater than seventy or lack of consent for surgery. Operative approaches for cerebral aneurysm were selected so as to minimize brain retraction. For example, the interhemispheric approach was used for ACo AN, and the transsylvian approach for IC and MC AN together with methods to decrease brain volume (ventricular drainage, mannitol administration, etc). Management of cerebrospinal fluid, decompressive procedures, or hypervolemic and hypertension therapy were occasionally performed. Clinical results were discussed in terms of clinical grading for cerebral aneurysms. Overall mortality was 70 cases (19%) and morbidity 65 cases (17.7%). Forty out of 46 cases with conservative treatment died. Two hundred and thirty-two out of 322 operated cases (72%) recovered, 30 cases (9.3%) died, and 60 cases (18.6%) were dependent. Causes of poor clinical outcome (135 cases, 36.7% of total) related to the severity of the attack (39 cases, 28.9%), re-attack after the admission (23 cases, 17%), vasospasm during the hospital course (42 cases, 31.1 %), operative complications (16 cases, 11.9%) and other complications (15 cases, 11.1%). Vasospasm was the most important cause of poor outcome in the mild to moderately ill patients, whereas intracerebral hematoma was the most important cause of poor outcome among the severely ill. Good clinical outcomes in severely ill cases were linked with operative timing following the attack and cause of severity. It was also pointed out that the operative procedures and techniques played important roles in outcome in acute surgery.