Timing of intracranial direct operation in ruptured cerebral aneurysms especially from analysis of rebleeding during the period of preoperative management (author's transl)

Abstract

Analysis of the various factors influencing rebleeding during the period of preoperative management has been carried out on 147 patients with intracranial aneurysms. The timing of operation in the ruptured intracranial aneurysm was discussed from the results of this study. Rebleeding occurred in 15 of 147 patients while waiting for surgery. Factors highly related with rebleeding during the period of preoperative management were as follows; grade II, major bleeding associated with loss of consciousness at the last subarachnoid hemorrhage, arteriosclerosis, acute stage within 7 days especially within the first 3 days after the last bleeding, IC-PC aneurysms, large and multilocular aneurysms, and diffuse and severe vasospasm. The ideal time for the surgery of grade I and grade II patients in the acute stage is within 24 hours after admission, preferably within a few hours, since incidences of rebleeding after admission are very high in acute grade I and II, especially in grade II patients, with very low operative mortality. The optimal time of the direct operations of grade III and IV patients should be as early as possible if the aneurysm has high tendency of rebleeding. It should be delayed if the patient has few factors of rebleeding, as mentioned above. The death rate is almost 100 % in conservatively treated patients in Hunt's grade V. Although few patients in this clinical state can be restored to fair conditions by early surgical interventions, such as external or internal decompressions, ventricular drainage, or direct operation of the aneurysm, the operative mortality rate should be assessed against the natural death rate, which is close to 100 %. A very high operative mortality rate should be acceptable. For this reason, early operative procedures for intracranial lesions and aneurysms seems to be indicated even in grade V patients.