Clipping of Aneurysms

Craniotomy and aneurysm obliteration by clipping has, until now, been the most effective treatment known. Timing of surgery, however, is still an important and controversial consideration in the management of the patient with a ruptured aneurysm.

Until the 1980s, late surgery was generally practiced. With improvements in microsurgical techniques and intensive care of patients, the Cooperative Study on the Timing of Aneurysm

Surgery was set up in an effort to establish outcome related to timing of surgery. This was a prospective, observational, epidemiological survey using the patient's neurological and disability status at 6 months, rates of vasospasm and re-bleed and medical and surgical complications as outcome measures. The mortality associated with intervening events in patients treated with delayed surgery was nearly equal to the post-operative mortality after early surgery [9,13]. However, rates of good recovery were significantly improved with early surgery, a good outcome being seen in 70.9% of those operated on at 0-3 days but only 61.7% if surgery was performed at greater than 10 days [13]. There tended to be similar technical difficulties in early and delayed surgery, although a swollen, tight brain was more frequent in patents operated on acutely. Other studies have shown a similar tendency, with early surgery resulting in a more favorable outcome with an equally common risk of adverse intra-operative events in those patients operated on early or late.

Early surgery, with manipulation of the basal cerebral blood vessels, was initially thought to increase the risk of vasospasm. This is probably untrue, as there appears to be no specific relationship between the timing of surgery and the onset of spasm or the development of cerebral infarction, as long as hypervolemia is initiated early. However, patients with surgery planned at days 7-10 (the time of greatest vasospasm) do have the least favorable outcome, with the highest mortality and incidence of focal deficits secondary to vasospasm [14].

Basilar trunk aneurysms are traditionally treated at 10-14 days following SAH, although recent studies have shown good results with early surgery. In addition, aneurysms greater than 2.5 cm are also best treated in a delayed manner, as technical difficulties increase in these individuals, with intraluminal clot, wide neck and prolonged periods of vessel occlusion.

Neurological grade and age of the patient are the most important patient-related factors.

The Cooperative Study showed that if patients were alert at admission, outcome was favorable in 75% at 6 months, while only 11% who were admitted in coma made a good recovery [9]. Traditionally, poor-grade patients are treated in a delayed manner, although they do not appear to tolerate surgery any worse than

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