Elsevier

Surgical Neurology

Volume 35, Issue 2, February 1991, Pages 152-158
Surgical Neurology

Unfavorable outcome following early surgical repair of ruptured cerebral aneurysms-A critical review of 238 patients

https://doi.org/10.1016/0090-3019(91)90269-FGet rights and content

Abstract

Among 238 consecutive patients admitted early with ruptured cerebral aneurysms, surgical repair within 48–72 hours was feasible in 200 cases. Unfavorable outcomes among the latter 200 patients are analyzed and discussed in this paper. Preoperatively, 148 patients were in Hunt and Hess grades I-III, 33 were in grade IV, and 19 in grade V. After clipping of the aneurysm, all patients received a regimen of topical intracisternal and intravenous/ peroral medication with the calcium antagonist nimodipine. The overall rate of unfavorable outcomes was 25%, ie, outcome with moderate or severe deficit or lethal outcome. The reasons for unfavorable outcomes among these 49 patients were the devastating effect of the bleed (severe subarachnoid hemorrhage or additional intracerebral hemorrhage) in 31 patients (15% of the 200 patients), a surgical complication in 11 (5.5%), preoperative rebleeding in three (1.5%), delayed ischemia from vasospasm in one (0.5%), and various others in three further patients (1.5%). Unfavorable outcome occurred in 11% of patients with preoperative grades I-III, in 52% of patients with grade IV, and in 16 of 19 patients with grade V. Among the 141 patients with subarachnoid hemorrhage but not intracerebral or intraventricular hematoma, 16 made an unfavorable outcome, ie, 11% versus 56% among patients with intracerebral hematoma/intraventricular hematoma on preoperative computed tomography scan. The present data seem to speak in favor of early surgery. Since half of the patients with intracerebral hematoma and poor outcome had suffered previous warning leaks, it appears to be a continuing challenge to diagnose warning leaks before a massive hemorrhage occurs.

References (53)

  • TH Milhorat

    On clipping acutely ruptured intracranial aneurysms

    Surg Neurol

    (1986)
  • TH Milhorat et al.

    Results of early and delayed operation for ruptured intracranial aneurysms in two series of 100 consecutive patients

    Surg Neurol

    (1986)
  • HP Adams

    Early management of the patient with recent aneurysmal subarachnoid hemorrhage

    Stroke

    (1986)
  • HP Adams et al.

    Early management of aneurysmal subarachnoid hemorrhage

    J Neurosurg

    (1981)
  • GS Allen et al.

    Cerebral arterial spasm-a controlled trial of nimodipine in patients with subarachnoid hemorrhage

    N Engl J Med

    (1983)
  • N Aoyagi et al.

    Analysis of 223 ruptured intracranial aneurysms with special reference to rupture

    Surg Neurol

    (1984)
  • LM Auer

    Acute operation and preventive nimodipine improves outcome in patients with ruptured cerebral aneurysms

    Neurosurgery

    (1984)
  • LM Auer

    Acute surgery of cerebral aneurysms and prevention of symptomatic vasospasm

    Acta Neurochir (Wien)

    (1983)
  • LM Auer

    Pial arterial vasodilatation by intravenous nimodipine in cats

    Drug Res

    (1981)
  • LM Auer

    Prevention of delayed ischaemic deficit and improvement of outcome by acute aneurysm surgery and nimodipine

  • LM Auer

    Timing of aneurysm surgery

  • LM Auer et al.

    Nimodipine and early aneurysm operation for good condition SAH patients

    Acta Neurochir (Wien)

    (1986)
  • LM Auer et al.

    Aneurysm surgery in the acute stage

  • LM Auer et al.

    Effect of topical nimodipine versus its ethanol-containing vehicle on cat pial vessels

    Stroke

    (1986)
  • LM Auer et al.

    Human pial vascular reactions to intravenous nimodipine infusion during EC-IC bypass surgery

    Stroke

    (1983)
  • LM Auer et al.

    Computerized tomography after early aneurysm surgery

    J Neurosurg

    (1986)
  • HG Bolander et al.

    Retrospective analysis of 162 consecutive cases of ruptured intracranial aneurysm

  • L Brandt et al.

    Effects of extracellular calcium and of calcium antagonists on the contractile responses of isolated human pial and mesenteric arteries

    J Cereb Blood Flow Metab

    (1981)
  • CG Drake

    Management of cerebral aneurysm

    Stroke

    (1981)
  • HR Eggert et al.

    Postoperative course following acute and delayed operation on cerebral aneurysm

  • ES Flamm et al.

    Dose-escalation study of intravenous nimodipine in patients with aneurysmal subarachnoid hemorrhage

    J Neurosurg

    (1988)
  • H Friedrich et al.

    Vergleichende Untersuchung zur Früh- und Spätoperation in der Aneurysma-machirurgie

    Neurochirurgia (Stuttg)

    (1985)
  • JM Gilsbach et al.

    Early aneurysm operation and vasospasm

  • J Gilsbach et al.

    Early aneurysm surgery: a 7 year clinical practice report

    Acta Neurochir (Wien)

    (1988)
  • J Hillman et al.

    Significance of “ultra-early” rebleeding in subarachnoid hemorrhage

    J Neurosurg

    (1988)
  • H Hugenholtz et al.

    Considerations in early surgery ongoodrisk patients with ruptured intracranial aneurysms

    J Neurosurg

    (1982)
  • Cited by (0)

    View full text