Prognosis of Aneurysmal Subarachnoid Hemorrhage: Prospective Study on 543 Patients

Abstract

Prevention of rebleeding and cerebral vasospasm is essential for the prognosis of aneurysmal subarachnoid hemorrhage (SAH). Only early elimination of the re-bleeding risk permits appropriate management of SAH and its sequelae due to cerebral vasospasm [2, 3]. Since March 1984 we therefore use a more aggressive management strategy [5, 7]: As soon as the diagnosis of SAH is made, i.v. administration of nimodipine is started. Earliest operation follows except for patients grade IV/V (according to Hunt and Hess) without relevant intracranial hematoma [12] and those harboring aneurysms of the proximal basilar artery. The morbidity of early surgery will be reduced by:

• 1. Use of external ventricular drainage [6] for preoperative lowering of intracranial pressure (ICP), increase of intraoperative space, and reduction of surgical trauma. It is further advantageous for postoperative ICP monitoring and clearing of bloody CSF.

• 2. Use of intraoperative “brain protection” (isoflurane/Brevimytal) [8]

• 3. Liberal temporary clipping [11]

• 4. Induction of hypertonia/hypervolemia immediately after definitive clipping [4]

• 5. Intravenous and cisternal administration of nimodipine

• 6. Controlled hypotension in basilar aneurysm only