Surgical problems and pathophysiology in severe cases with ruptured aneurysm in the acute stage.

We have managed 674 cases of ruptured aneurysms of the anterior part of the circles of Willis during the period 1969 to 1980. For this study, analyses were made to clarify the operative indication, timing and suitable procedures based on the pathophysiology of severe cases in the acute stage. Clinical results on conservative treatment in the era of delayed operation clearly show the inevitable necessity of early operation. The CBF measurement in the acute stage revealed a slight decrease of hemispheric CBF without regulatory dysfunction of cerebral circulation within 3 days of SAH. Results of early operation within 3 days of SAH in the 3rd era showed that 83.1% of cases survived with a good outcome and 3.4% died when they were in Grades 1 and 2. 40 cases with severe grading, operated on within 3 days of SAH, were studied on each site of the aneurysm. Mortality was 12.5% and there was a favourable outcome in 55%. Death was due to brain swelling caused by vasospasm and direct brain damage caused by SAH and an intracerebral haematoma. Extensive evacuation of subarachnoid clotting could be performed only when brain volume could be reduced enough to minimize brain compression, by using ventricular drainage, evacuation of the intracerebral haematoma and Mannitol administration. Surgical procedures for each aneurysm are also described.