Recent Subarachnoid Hemorrhage Research Articles

Considerations for delayed-onset spinal arachnoid web after intracranial subarachnoid hemorrhage

Abstract: Spinal arachnoid web (AW) is a rare condition causing spinal cord-related issues. Its cause is often idiopathic but can be linked to past trauma or spine surgery. We describe two cases of AWs that developed after subarachnoid hemorrhage (SAH). Case #1 is a 71-year-old male with nonaneurysmal SAH who developed myelopathy 1 year later. Magnetic resonance imaging revealed upper thoracic cord edema and an AW. Case #2 is a 57-year-old female who underwent coiling of a ruptured basilar artery aneurysm and ventriculoperitoneal shunting for hydrocephalus. Twenty months later, she developed mid-thoracic AW requiring surgical resection. Both patients showed symptom improvement postresection avoiding further reoperation. History of SAH is emerging as a risk factor for AW development, emphasizing the importance of monitoring delayed-onset myelopathy and back pain in recent SAH patients.

Phenytoin-Induced Ataxia and Diplopia in a Patient with Recent Subarachnoid Hemorrhage: A Case Report

This case report presents a 25-year-old male with a complex medical history, including a recent subarachnoid hemorrhage (SAH) and a prescription for phenytoin. The patient exhibited neurological symptoms, such as ataxia, blurring of vision, and diplopia, prompting an intricate diagnostic evaluation. The medical history encompassed a prior road traffic accident resulting in a jaw injury, adding to the complexity of potential aetiologies, including cerebellar dysfunction, sequelae from the accidents, medication-related side effects (particularly phenytoin), or infectious/inflammatory causes. Given the reported symptoms, there arose a suspicion of phenytoin-induced ataxia and diplopia, common neurological side effects associated with this anticonvulsant. These symptoms, suggestive of cerebellar dysfunction, required a comprehensive examination, including neurological assessments and imaging studies, to elucidate the precise etiology. This case underscores the importance of meticulous medication review, particularly for drugs like phenytoin, and emphasizes the necessity of a multidisciplinary approach involving neurologists to navigate the complexities associated with neurological manifestations in the context of SAH and medication use. The findings contribute to understanding potential complications arising from anticonvulsant therapy in SAH patients and highlight the need for tailored diagnostic and management strategies in such intricate clinical scenarios.

Pharmacokinetics of amphotericin B after accidental overdose in an adult critically ill patient treated with plasmapheresis: a case report and review of literature

Amphotericin B is a broad-spectrum antifungal agent that is used in the treatment of systemic fungal infections. We describe the case of a 62-year-old female patient with recent aneurysmal subarachnoid hemorrhage who was treated for suspected ventriculitis and a fungal coinfection. Instead of liposomal amphotericin B (L-AmB), 465 mg (5 mg/kg) amphotericin B deoxycholate (DOC) was inadvertently administered, leading to refractory shock with multiple organ failure and requiring mechanical ventilation. Since an overdose of amphotericin B can lead to fatal consequences and has a half-life of 15 days, plasmapheresis was started. The serum concentration decreased from 1.32 µg/mL to 0.62 µg/mL before plasmapheresis, demonstrating a mean half-life of 49 hours. After two plasmapheresis sessions, the serum concentration further dropped to 0.26 µg/mL, demonstrating a mean half-life of 17 hours. In contrast, the third plasmapheresis session had no effect on serum concentration. The patient made a full recovery, potentially facilitated by enhanced amphotericin B elimination through plasmapheresis. Positive outcomes were previously reported in two adult patients treated with plasmapheresis. However, other reports without plasmapheresis described fatal outcomes in adult patients, albeit with a twofold overdose compared to the two patients successfully treated with plasmapheresis. Moreover, plasmapheresis itself carries risks such as hypocalcemia, metabolic alkalosis, and coagulation deficits. Consequently, the role of plasmapheresis in amphotericin B overdose is still debated.

Percutaneous Mechanical Thrombectomy for Acute Symptomatic Iliofemoral Deep Venous Thrombosis Patients With Recent Aneurysmal Subarachnoid Hemorrhage

Purpose: To investigate the efficacy, safety, and mid-term outcomes of percutaneous mechanical thrombectomy (PMT) for acute symptomatic iliofemoral deep venous thrombosis (DVT) patients with recent (within 4 weeks) aneurysmal subarachnoid hemorrhage (aSAH). Materials and methods: From January 2016 to February 2020, 11 acute symptomatic iliofemoral DVT patients with a recent history of aSAH were enrolled in this study. All patients had a history of aneurysm ligation or clipping previously, computed tomography (CT) scans revealed ventricular hemorrhage had been absorbed obviously and no residual aneurysm. The mean time of DVT onset after aSAH ictus was 19.2±4.5 days, and the mean Glasgow score was 6.8 ± 0.7 (range, 6–8). These patients underwent PMT with an 8 French Aspirex®S device (Straub Medical AG, Wangs, Switzerland), subsequent stenting was performed to relieve the underlying stenosis, followed by anticoagulation alone. The procedure-related complications were assessed after intervention. The follow-ups were conducted up to 1 year, the patency was evaluated via duplex ultrasonography, and the incidence of post-thrombotic syndrome (PTS) was evaluated using the Villalta scale. Results: Grade III (>90%) clearance was achieved in all 11 patients. Stenting was performed in 7 patients (63.6%). There were no cerebral rebleeding events or other severe complications except 1 puncture site bleeding during treatment. A total of 90.9% (10 of 11) of patients were alive at the 12 month follow-up, and 7 patients achieved a good functional outcome. At the 1 year follow-up, there was 1 patient (10%) with mild PTS. The ultrasound showed that the patency of the iliofemoral veins was 100%, and femoral valvular incompetence was observed in 1 patient. Conclusion: Percutaneous mechanical thrombectomy seems to be a feasible and safe treatment for acute iliofemoral DVT in selected patients with recent aSAH, and it shows promising results in restoring patency and reducing the risk of PTS.

Presigmoid Transpetrosal Approach for Superficial Temporal Artery to Distal Posterior Cerebral Artery Bypass and Trapping of Aneurysm.

BACKGROUND AND IMPORTANCEAneurysms of the posterior cerebral artery (PCA) are uncommon, estimated at less than 1% of all cerebral aneurysms, and less than half occur distal to the P1/2 junction. Unfortunately, the conventional bypass approach for PCA aneurysms—primarily occipital artery to distal PCA cortical branches—has a history of unsatisfying results.CLINICAL PRESENTATIONA 42-yr-old female presented with Fisher 3 Hunt-Hess 2 subarachnoid hemorrhage secondary to ruptured distal PCA aneurysm. She was initially evaluated by the endovascular service, but due to recent subarachnoid hemorrhage, endovascular treatment with flow diversion and/or vessel sacrifice was felt to be relatively contraindicated and the patient was referred for surgical evaluation for possible bypass. The patient subsequently underwent surgery for trapping of aneurysm and concomitant superficial artery to distal PCA bypass.CONCLUSIONA novel approach for the treatment of a ruptured distal PCA aneurysm is described, consisting of posterior transpetrosal exposure and division of the tentorium with superficial temporal artery to P3 bypass.

Destroyed thyroid by acidic blood during subarachnoid hemorrhage: Experimental study

Aim: Metabolic acidosis can negatively affect thyroid functions. The aim of this study is to show the damage in the thyroid gland caused by acidosis following subarachnoid hemorrhage (SAH). Methods: Twenty rabbits were chosen from our recent SAH studies. Five healthy rabbits were included in the control group, five were included in the SHAM group, which received 1 ml of saline, and ten rabbits, chosen from SAH-induced animals with decreased blood pH, constituted the study group. TSH, T3, T4 and blood pH values were recorded before, during and after the experimental procedures. Densities of the normal and degenerated epithelial cell of thyroid glands were estimated using stereological methods. The relationship between blood pH and thyroid hormone values, and degenerated epithelial cell densities were analyzed statistically.Results: pH values of blood were measured as 7.35 (0.037), 7.32 (0.05), and 7.21 (0.012) in the control, SHAM and SAH groups, respectively. The estimation of normal and degenerated epithelial cells per square milimeter of follicles was calculated as wall surface/cell surface. The mean normal epithelial cell count was 5,000 (750) in normal thyroid follicles. Mean degenerated epithelial cells counts were 50 (9) in the normal group, 154 (30) in the SHAM group and 460 (80) in the study group. For all results there was statistically significant difference between the control, SHAM and SAH groups (P<0.001).Conclusions: Acidosis, one of the most fatal complications of SAH, may damage the thyroid gland with neurovascular network degeneration.

Surface Point Cloud Ultrasound with Transcranial Doppler: Coregistration of Surface Point Cloud Ultrasound with Magnetic Resonance Angiography for Improved Reproducibility, Visualization, and Navigation in Transcranial Doppler Ultrasound.

Transcranial Doppler (TCD) ultrasound is a standard tool used in the setting of recent sub-arachnoid hemorrhage (SAH). By tracking velocity in the circle-of-Willis vessels, vasospasm can be detected as interval velocity increase. For this disease process, repeated TCD velocity measurements over many days is the basis for its usefulness. However, a key limitation to TCD is its user dependence, which is itself largely due to the fact that exact information about probe positioning is lost between subsequent scans. Surface point cloud ultrasound (SPC-US) was recently introduced as a general approach combining ultrasound and three-dimensional surface imaging of patient + probe. In the present proof-of-principle demonstration, we have applied SPC-US to TCD and co-registered the skin surface with that from MRA images to provide a roadmap of the vasculature in 3D space for better speed, accuracy, reproducibility, and potential semi-automation of TCD. Collating the acronyms, we call the combined approach SPC-US-TCD. TCD of the M1 was obtained while three-dimensional photographic images were obtained with the Structure Sensor camera. MRA imaging was also obtained. SPC-US-TCD and corresponding MRA 3D reconstruction images were co-registered in MeshMixer using the skin surfaces for alignment. A cylinder the width of the TCD probe was placed over the fused images and aligned with the direction and orientation of the TCD probe to demonstrate the acoustic beam. In the fused images, the acoustic beam intersects the right M1 segment of the middle cerebral artery (MCA). The angle of insonation is well demonstrated and measurable in various planes. Distance measurements made in Blender localized the TCD probe position based on three skin surface landmarks, and tabulated orientation based on three angles along the corresponding directions. SPC-US-TCD provides valuable information that is otherwise not present in TCD studies. By co-registering SPC-US-TCD data with that from cross sectional vessel imaging, precise probe location relative to external skin surface landmarks as well as 3D vessel location relative to TCD probe placement offers the potential to provide a roadmap that improves exam reproducibility, speed of acquisition, and accuracy. The goal of future work is to demonstrate this improvement statistically by application to multiple patients and scans.

Rebleeding from Cerebral Aneurysms during 3DCT Angiography

Background and purpose: Computed Tomographic Angiography (CTA) is commonly used for the non-invasive detection of cerebrovascular lesions responsible for subarachnoid hemorrhage, but rebleeding may occur during this procedure. We investigated imaging findings and related factors in patients who experienced rebleeding during CTA in our hospital. Materials and methods: Participants comprised 112 patients who underwent CTA for ruptured cerebral aneurysm in our hospital between January 10 and December 2015. CTA was performed using a 64-row detector system. Results: Rebleeding occurred during CTA in 5 of 112 patients, representing a rebleeding rate of 4.5%. Mean time from initial onset of hemorrhage to CTA was shorter in patients with rebleeding (median, 88 min) than in patients without rebleeding (median, 228 min; P=0.051), and blood pressure at the time of initial treatment tended to be higher for patients with rebleeding. Patients with rebleeding showed either: a) spiral or wave-shaped hemorrhage into the cistern in which the aneurysm was located; or b) tear-drop-shaped hemorrhage within the hematoma. Patients with rebleeding were all grades 5 according to the World Federation of Neurological Surgeons (WFNS) and underwent CTA within 3 h of onset. Conclusion: CTA offers excellent performance for the diagnosis of cerebral aneurysm, but the use of intravenous contrast agent may carry some risk of rebleeding. History of recent severe subarachnoid hemorrhage also appears to represent a risk factor for rebleeding. As contrast agent injection may produce hemodynamic effects, management of fluctuations in blood pressure during CTA is crucial.

Augmented Renal Clearance in Patients with Subarachnoid Hemorrhage.

Patients with subarachnoid hemorrhage (SAH) typically exhibit hyperdynamic cardiovascular hemodynamics, which may lead to increased medication clearance. The aims of this study were to evaluate the actual creatinine clearance (CrClA) in an aneurysmal SAH population and the effect of the development of cerebral vasospasm (CV) along with its treatment to better understand if this population exhibits augmented renal clearance (ARC). This was a prospective, single-center study in a neurosciences ICU at a university hospital. A total of 20 patients were consented and provided a 24-h urine sample to measure the CrClA. If patients experienced CV, a 24-h urine collection was repeated during vasospasm treatment. CrClA was measured using a modified Jaffe assay. Among the 20 patients enrolled, the mean SAH CrClA was 325.93±135.20ml/min1.73m(2) and this differed significantly from the SAH estimated creatinine clearance (CrClE) 144.93±42.82ml/min1.73m(2) (p<0.001). Four patients developed CV; the mean CV CrClA was 558.43±356.12ml/min1.73m(2) and there was no significant difference when compared to those patients' mean SAH CrClA (246.91±84.14ml/min1.73m(2), p=0.16). ARC was present in 100% of the patients with recent SAH enrolled. Although ARC remained present in the patients who experienced CV, their creatinine clearance was not significantly further augmented. Further work is needed to clarify the impact of such clearances on renally excreted medications and how the development and treatment of CV further augment these findings.

HIMALAIA (Hypertension Induction in the Management of AneurysmaL subArachnoid Haemorrhage with Secondary IschaemiA): A Randomized Single-Blind Controlled Trial of Induced Hypertension vs. no Induced Hypertension in the Treatment of Delayed Cerebral Ischemia after Subarachnoid Hemorrhage

Delayed cerebral ischemia (DCI) is a major complication after aneurysmal subarachnoid hemorrhage (SAH). One option to treat delayed cerebral ischemia is to use induced hypertension, but its efficacy on the eventual outcome has not been proven in a randomized clinical trial. This article describes the design of the HIMALAIA trial (Hypertension Induction in the Management of AneurysmaL subArachnoid haemorrhage with secondary IschaemiA), designed to assess the effectiveness of induced hypertension on neurological outcome in patients with DCI after SAH. To investigate whether induced hypertension improves the functional outcome in patients with delayed cerebral ischemia after SAH. The HIMALAIA trial is a multicenter, singe-blinded, randomized controlled trial in patients with DCI after a recent SAH. Eligible patients will be randomized to either induced hypertension (n = 120) or to no induced hypertension (n = 120). In selected centers, the efficacy of induced hypertension in augmenting cerebral blood flow will be measured by means of cerebral perfusion computerized tomography scanning. Follow-up assessments will be performed at 3 and 12 months after randomization by trial nurses who are blinded to the treatment allocation and management. We will include patients during five years. The primary outcome is the proportion of subarachnoid hemorrhage patients with delayed cerebral ischemia with poor outcome three-months after randomization, defined as a modified Rankin scale of more than 3. Secondary outcome measures are related to treatment failure, functional outcome, adverse events, and cerebral hemodynamics. The HIMALAIA trial is registered at clinicaltrials.gov under identifier NCT01613235.

022 Ischemic stroke versus bleeding risk in patients with acutely ruptured saccular aneurysms treated with stent assisted coiling

Introduction: Antiplatelet agents are required to prevent thromboembolic complications from recently deployed intracranial stents, yet carry a risk of bleeding complications that may be serious in patients with recent subarachnoid...

Hypotension in anaesthetized patients during aneurysm clipping: not as bad as expected?

Patients with aneurysmal subarachnoid haemorrhage (SAH) often have disturbed autoregulation of cerebral blood flow. A reduction in systemic blood pressure during surgery may therefore lead to delayed cerebral ischaemia (DCI). To assess the incidence and severity of intra-operative hypotension, we performed a retrospective cohort study in 164 patients with recent SAH and surgical clipping of the aneurysm. Intra-operative hypotension was defined in three levels of severity, as a decrease in mean arterial pressure (DeltaMAP) of more than 30%, 40% or 50% compared with the pre-operative pressure. For each patient the total amount of time with intra-operative hypotension was retrieved. Logistic regression analysis was performed to study the relation between intra-operative hypotension and the occurrence of DCI and poor outcome. A period with DeltaMAP>30% occurred in 128 patients (78%) with a median duration of this period of 105 min (25-75 per thousand 50-171 min). DeltaMAP>40% occurred in 88 patients (54%) and DeltaMAP>50% occurred in 22 patients (13%). In univariate analysis, DeltaMAP>50% was associated with poor outcome. After adjusting for age and World Federation of Neurological Surgeons grade, the association with poor outcome was no longer statistically significant [odds ratio (OR) 1.018; 95% CI 0.996-1.041]. Hypotension during surgical clipping of intracranial aneurysms occurred frequently. In our study population of patients mostly in good clinical condition, hypotension was not confirmed as an independent risk factor for DCI or poor outcome. Anaesthesia may have had a cerebral protective effect.

Intravenous Nicardipine

Nicardipine is a water soluble calcium channel antagonist, with predominantly vasodilatory actions. Intravenous (IV) nicardipine (Cardene IV), which demonstrates a relatively rapid onset/offset of action, is used in situations requiring the rapid control of blood pressure (BP). IV nicardipine was as effective as IV nitroprusside in the short-term reduction of BP in patients with severe or postoperative hypertension. A potential role for IV nicardipine in the intraoperative acute control of BP in patients undergoing various surgical procedures (including cardiovascular, neurovascular and abdominal surgery), and in the deliberate induction of reduced BP in surgical procedures in which haemostasis may be difficult (e.g. surgery involving the hip or spine) was demonstrated in preliminary studies. Preliminary studies also indicated the ability of a bolus dose of IV nicardipine to attenuate the hypertensive response, but not the increase in tachycardia, after laryngoscopy and tracheal intubation in anaesthetised patients. In large, well designed studies, IV nicardipine prevented cerebral vasospasm in patients with recent aneurysmal subarachnoid haemorrhage; however, overall clinical outcomes at 3 months were similar to those in patients who received standard management. Small preliminary studies have investigated the use of IV nicardipine in a variety of other settings, including acute intracerebral haemorrhage, acute ischaemic stroke, pre-eclampsia, acute aortic dissection, premature labour and electroconvulsive therapy.In conclusion, the efficacy of IV nicardipine in the short-term treatment of hypertension in settings for which oral therapy is not feasible or not desirable is well established. The ability to titrate IV nicardipine to the tolerance levels of individual patients makes this agent an attractive option, especially in critically ill patients or those undergoing surgery. Potential exists for further investigation of the use of this agent in clinical settings where a vasodilatory agent with minimal inotropic effects is appropriate.

Stent-assisted coil embolization of intracranial wide-necked aneurysms

The endovascular treatment of cerebral aneurysms with coils poses significant technical challenges, particularly with respect to wide-necked aneurysms. We present the results of our initial experiences in using a stent for endovascular treatment of aneurysms, with an emphasis on potential applications, technical aspects, and associated complications. Twenty-three wide-necked aneurysms from 22 patients were treated during the 13-month study period. Seven patients presented with subarachnoid hemorrhage. Aneurysms were located at the internal carotid artery (n=14), the vertebral artery (n=3), the basilar artery (n=5), and the middle cerebral artery (n=1). A Neuroform stent2 was used for stent-assisted procedures. Premedication with antithrombotic agents was available for unruptured cases. Postprocedural antithrombotic medication was prescribed for all patients. Nineteen aneurysms were primarily stented, followed by coil placement. For five of these aneurysms, stenting was performed subsequent to failure of an attempt to frame with an initial coil. Stenting for the remaining four aneurysms was performed as a rescue procedure to prevent the migration of previously placed coils. Complete occlusion was obtained in ten aneurysms, nearly complete occlusion (95% or more occluded) in 11 aneurysms, and partial occlusion (less than 95% occluded) in one aneurysm. In one aneurysm, we failed to navigate the microcatheter into the aneurysmal sac through the interstices of the stent. Stent thrombosis was noted during the procedure in one patient. Hemorrhagic complication on the 25th day after the procedure was noted in one patient. No procedure-related complications were observed during the procedure or during follow-up in the remaining 20 patients, including seven patients who did not receive antithrombotic agents prior to endovascular treatment owing to recent subarachnoid hemorrhage. To overcome the technical limitation in the coiling of wide-necked aneurysms, stent-assisted coil embolization may be a technically feasible and relatively safe method, even though longer periods of follow-up are required.

A 70-Year-Old Woman With Poor Grade Subarachnoid Hemorrhage Complicated by Carotid Stenosis, Cerebral Vasospasm, and Cerebral Rebleed

Subarachnoid hemorrhage is one of the most common entities encountered in neurocritical care units. Knowledge of disease sequelae and their management is paramount for all neurointensivists. This study relates the case of a 70-year-old woman with poor grade subarachnoid hemorrhage who underwent endovascular detachable coil embolization of a right internal carotid artery aneurysm. Her hospital course was subsequently complicated by symptomatic carotid stenosis and cerebral vasospasm requiring intervention. The discussants present their views regarding five main questions pertaining to management of the patient regarding the choice of endovascular versus surgical aneurysm occlusion, stent-supported angioplasty in a patient with a recent subarachnoid hemorrhage, and treatment options for vasospasm.

Anesthetic management of deep hypothermic circulatory arrest for cerebral aneurysm clipping.

This article will briefly review the rationale for DHCA in the setting of cerebral aneurysm treatment. We will then use the main aspects of the protocol practiced by the senior author (WLY), as a point of departure to review the issues regarding anesthetic and perioperative management. Rationale The ability to temporarily eliminate or reduce blood flow into an aneurysm gives the surgeon an important advantage—without flow, an aneurysm is converted from a hard, pulsating mass into a soft, collapsed sac, allowing more aggressive manipulation of the aneurysm to complete its dissection. With most aneurysms, temporary occlusion of the proximal parent artery or arteries will effectively control blood flow into the lesion. With large or complex aneurysms, the aneurysm mass may prevent optimal visualization and clip application to the neck. Collapse of the aneurysm mass creates more working space for dissection and precise clip application. Deep hypothermic circulatory arrest is used for aneurysms that cannot be adequately controlled by conventional surgical or endovascular techniques. Aneurysms in the anterior circulation are, in general, accessible enough to be managed with temporary clipping. Aneurysms that defy conventional treatment are typically in the posterior circulation and large (10 –25 mm in diameter) or giant (25 mm in diameter) in size. 11 Often these aneurysms cannot be collapsed easily because of the breadth of the neck, the complexity of the arterial branches at the base, the presence of thrombus or endovascular coils in the lumen, artheroma or calcium in the walls, and fusiform configuration. These anatomic features make direct clipping more difficult and lower the efficacy of conventional techniques. The surgeon’s ability to manage these anatomic factors is directly related to operative exposure. When proximal and distal arteries are inaccessible with these complex aneurysms, DHCA may provide the only safe and effective means of vascular control. Deep hypothermic circulatory arrest should be considered an option of last resort for these unusual aneurysms, when all conventional techniques have failed or have been carefully considered. Rarely, DHCA has also been proposed or described for other central nervous system lesions, such as tumors 8 or arteriovenous malformations, 12 but this discussion is not

Eyebrow incision for combined orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of the anterior circulation. Technical note.

A modification of the supraorbital keyhole approach, the eyebrow incision-minisupraorbital craniotomy with orbital osteotomy, is described. Unique to this approach is a one-piece supraorbital craniotomy, measuring 2.5 x 3.5 cm, that incorporates the orbital rim and roof and the frontal process of the zygomatic bone through an eyebrow incision. The orbital osteotomy facilitates view of the anterior and middle cranial fossa through the operating microscope, as well as the maneuverability of instruments through a small craniotomy. A pericranial flap is elevated with its base at the orbit and used for closure of the frontal sinus, if necessary. The approach was used successfully in elective surgery of 10 aneurysms of the anterior circulation. The mean aneurysm size was 5.9 mm, with a range of 4 to 10 mm. Advantages of this approach include minimal disruption and exposure of normal brain tissue, reduced frontal lobe retraction, and an excellent postoperative cosmetic result. The approach is performed quickly by virtue of a limited skin incision with minimal temporalis muscle dissection and a small bone flap. The neuroendoscope, although helpful at times, is not essential and no special instruments or intraoperative image guidance is required. Relative contraindications include the presence of a large frontal sinus, severe brain edema, and recent subarachnoid hemorrhage. In addition, this approach has not been used for the treatment of giant intracranial aneurysms.

Feedback: Computed tomography for subarachnoid hemorrhage

Feedback: Computed tomography for subarachnoid hemorrhage

Surgical treatment of anterior circulation aneurysms

With few exceptions, aneurysm surgery is preventive surgery; the aim is to prevent a subarachnoid hemorrhage from the aneurysm—rebleeding after the first hemorrage or possibly first bleeding from a previously unruptured aneurysm. Consequently, surgical mortality and morbidity must not exceed natural mortality and morbidity. The natural risk of death from rebleeds after aneurysmat subarachnoid hemorrhage is about 35% immediately after the bleeding, and decreasing quickly to a level of approximately 2%/y. The annual bleeding rate of previously unruptured aneurysms is traditionally considered to be about 1.4% but can be much lower. For good-grade patients, the ideal time of surgery after a subarachnoid hemorrhage is the first days after bleeding. For previously unruptured aneurysms, the timing of surgery is not critical. Of the open, intracranial procedures, clipping of the aneurysm neck is the only widely used procedure today. Intravascular treatment is a new and possibly good alternative to open operations for intracranial aneurysms; however, surgery is still the standard aneurysm therapy. To minimize operative mortality and morbidity, the best possible perioperative conditions must be created. Preoperatively, if the patient has had a recent subarachnoid hemorrhage, standard care includes maintenance of stable and normal blood pressure and nimodipine to prevent possible ischemic complications in addition to good general care. Perioperatively, it is important to prevent ischemic complications and to create the best possible operative conditions with respect to intracranial space. The most common anterior circulation aneurysm locations are internal carotid artery, anterior communicating artery, middle cerebral artery, and pericallosal artery. The approach to all these aneurysm locations, with the exception of pericallosal aneurysms, is the pterional one, with possible small variations. The general principle of dissecting an aneurysm is to follow the parent vessel and identify the aneurysm neck. The aneurysm neck always must be dissected free from surrounding arteries and clipped with one or more aneurysm clips. Techniques used vary according to the location, but common for all is avoiding a lesion to any important artery and achieving a complete closure of the aneurysm neck. It is particularly difficult and important to avoid closure of the socalled perforating arteries close to anterior communicating artery and internal carotid artery aneurysms.

▪ Anaesthesia for Caesarean Section in a Patient with Recent Subarachnoid Haemorrhage and Severe Preeclampsia

▪ Anaesthesia for Caesarean Section in a Patient with Recent Subarachnoid Haemorrhage and Severe Preeclampsia