Advances in the management of victims struck by ruptured intracranial aneurysms

The advances in management of victims struck by the rupture of an intracranial aneurysm is reviewed. In the 1970s the management outcome was still far from acceptable; many victims who had 'recovered' following a major aneurysmal subarachnoid haemorrhage (SAH) succumbed or became crippled as the result of repeat bleeds and/or delayed SAH-induced ischaemic deterioration ('cerebral vasospasm'). The era of prosperity for microneurosurgery, the introduction of the calcium channel blocker nimodipine and the accumulation of cases in centres with a team of dedicated aneurysm surgeons form the basis of a recent breakthrough in the previously gloomy management outcome. With microsurgical techniques elective surgery can now be performed in the acute stage thereby preventing disastrous reruptures which occur frequently in the early phase after the first bleed. The concomitant use of nimodipine minimizes delayed SAH-induced ischaemic deterioration. Today a management regime including early operation combined with nimodipine has led to grossly improved results. Nevertheless cognitive disturbances and psychosocial maladjustment are frequent sequelae following a major aneurysmal bleed. Hope for further improvements could depend on the development of techniques which may allow identification of intracranial aneurysms before they rupture and increased knowledge of the aetiology of such cerebral arterial wall lesions.