Indications and Timing of Surgery on Ruptured Intracranial Aneurysms
Direct surgical obliteration of a ruptured intracranial aneurysm without the associated problem of subarachnoid hemorrhage (SAH) can be achieved with less than 2% mortality and 5% morbidity. This excellent progress, however, does not take into account two major aspects in the management of patients with SAH. First, a significant number of patients suffer secondary deterioration and never come to surgery. The outcome of these patients, when added to the surgical outcome, the management mortality, and morbidity, is still appalling. Second, and in my view more significantly, treatment of a patient with SAH over the last three decades has been identified with the control of the ruptured aneurysm, but treatment of the disease itself was largely ignored. This was primarily due to the fact that pathological changes associated with SAH were unrecognised and the method of identifying them with investigation, such as angiography, was itself harmful in a severely ill patient. With the introduction of the CT scan, Doppler ultra-sound, MRI and PET scan, it is now possible to assess the living pathology of SAH and specific treatment can be instituted. There is yet another challenge, not altogether at the control of the neurosurgeons, which awaits us for the future. As early as 1956, Walton  in Newcastle showed that one-third of these patients die from initial bleeding. This occurs even today. There is clear evidence from the study by Kassell and Drake  that two-thirds of these are due to ignored warning signs, misdiagnoses or late referral. An educational program illuminating the perils of SAH can aim to conquer the natural history of SAH from ruptured aneurysm.
KeywordsIntracranial Aneurysm Early Surgery Aneurysm Surgery Aminocaproic Acid Angiographic Vasospasm
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