The authors surveyed the follow-up results of 512 microsurgically-treated cases with ruptured cerebral aneurysms during the last 10 years and discussed the timing and indications of surgery for ruptured cerebral aneurysms. Among these cases, 54 underwent surgery of the aneurysm within 3 days after subarachnoid hemorrhage(SAH), 57 between day 4 (the SAH day was counted as day 1) and 8, and 72 cases in the second week. Operative mortality was 5.5%, and 82.2% of the total cases returned to their previous work.
The authors' principles of surgical treatment of ruptured cerebral aneurysms were as follows:
1) Patients in Grade 1 or 2 (Hunt's grading) can safely undergo operations on aneurysms on any day after SAH.
2) During the first 3 days after SAH, cases in Grade 3 can also be operated on. Nine out of 11 cases could lead useful social lives. However, in cases of Grade 4, microsurgery of aneurysms should be postponed during this period except cases with intracerebral hematoma. Washout of cisternal blood clots was not always easy and postoperative vasospasms which exert a crucial influence on the prognosis of patients could not be prevented. Only three out of nine cases returned to their previous work.
3) Between day 4 and day 8, surgery of aneurysms in cases of Grades 3 and 4 should be postponed. Our data showed that the operative mortality of these cases was highest (33.3%) due to development of postoperative vasospasms.
4) After day 8, any cases which exhibit neurological deterioration should be subjected to repeated angiographic examinations to detect vasospasms and to follow their course. If vasospasms are present, surgery should be postponed until the vasospasms begin to subside and disturbance of the consciousness begins to improve.
Early operations (during the first 3 days after SAH) did not always prevent development of postoperative vasospasms according to our data for the last 10 years. However, recent CT scans revealed that vasospasms did not develop when no cisternal blood clots were present and complete washout of these clots by early operations can be expected to prevent postoperative vasospasms.