Surgical planning

Aneurysm rebleeding is a catastrophic event that may occur relatively soon after the initial SAH.144 The frequency of rebleeding is 4% within the first 48 hours following the initial SAH and 15% each day for the next 12 days. The mortality rate from aneurysm rebleeding is at least 70%. Surgical or interventional treatments offer the best protection against rebleeding and its attendant complications.

Some neurosurgeons are concerned that surgery soon after acute SAH is technically more difficult due to brain swelling and obscuration of vital structures by acute blood within the subarachnoid space. Despite the above considerations, the majority of our grade 1-3 patients undergo surgery early after SAH to minimise the incidence of rebleeding. Although this surgery can be technically more demanding, we have not found patient morbidity and mortality to be adversely affected. We have found intraoperative ventricular puncture and aggressive gravity drainage of CSF to be an extremely useful adjunct in overcoming an initially swollen brain soon after SAH.170 The results of the most recent Cooperative Study confirm that although most surgeons report the brain to be significantly more swollen during early surgery, the majority feel early surgery is not significantly more difficult.156 In this Cooperative Study, early surgery reduced the incidence of rebleeding but had no effect in decreasing the incidence of vasospasm.171-174 Nevertheless, most patients were treated prior to the widespread use of triple H therapy and calcium channel blockers.

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