Aneurysm surgery in the acute stage: results of structured treatment

To evaluate the results of a structured treatment approach to aneurysm surgery in the acute stage, 150 consecutive patients with aneurysmal subarachnoid hemorrhage were studied, including 46 males and 104 females; World Federation of Neurological Surgeons grade I: 21 cases, II: 65, III: 41, IV: 23; day of operation < or = day 3: 103 cases, < or = day 7: 131. Patients underwent angiography on the day of admission or the next followed by surgery. The lamina terminalis and the membrane of Liliequest were routinely opened at surgery. The aneurysm neck was radically clipped after temporary clipping or trapping of the parent arteries. Intraoperative hemodynamic monitoring was used, and the craniotomies were closed without cisternal, epidural, or subgaleal drains. Nimodipine was given perioperatively (48 mg i.v./day for 10 to 14 days). Cases of symptomatic vasospasm were treated with selective intra-arterial administration of papaverine, sometimes combined with angioplasty. Outcome at discharge and 3 months later is good recovery in 61% and 75%, and death in 6% and 7%. The incidence of symptomatic vasospasm was 17%. Devastating vasospasms were observed in 5%. One-third of patients had mean flow velocities exceeding 120 cm/sec determined by transcranial Doppler sonography between days 4 and 14. Communicating hydrocephalus necessitating ventriculoperitoneal shunt occurred in 9%. Our results clearly show a favorable outcome compared with previous reports, especially with respect to the reduced occurrence of fatal vasospasm, hydrocephalus, and technical insufficiency.