Progress in cerebrovascular disease. Management of cerebral aneurysm.

The primary effort of neurosurgery over the past two or three decades has been to deal effectively with cerebral aneurysms surgically. Concomitantly with aggressive medical treatment, considerable progress has occurred in the prevention of early rebleeding and the treatment of the ischemic syndrome, the most serious features of the natural history of a ruptured aneurysm. The major problem now becoming evident is that in spite of this progress, the majority of patients are not seen by physicians and there has been only a small impact on the overall morbidity. It is dismaying to realize that many patients go unrecognized, at least until a massive brain-destroying hemorrhage has occurred. Only a small fraction of the patients are seen after the initial bleed when the greatest therapeutic reward would occur. The challenge for the future, then, will be the early recognition of the initial bleeding, the warning bleeding. It will require public education about the problem in a continuing fashion, as well as continuing emphasis on it for students and physicians. The potential for prevention of death or dreadful disability is large for thousands in the prime of life each year. While delayed surgery is safe, a significant amount of rebleeding and ischemia with vasospasm still occur, resulting in an unsatisfactory overall morbidity. A collaborative study is desirable to determine with sufficient patients whether very early modern operation in many hands will reduce this morbidity.