Timing of Aneurysm Surgery

Ruptured aneurysm is a major neurosurgical problem afflicting approximately 28,000 North Americans each year and resulting in death or disability in 18,000 of these patients. Vast improvements have been made in operative results for ruptured aneurysm during the past 3 decades, but have not been reflected in a proportional improvement in overall management results. The minority of patients ultimately undergo operation. Furthermore, most surgery is performed more than 1 to 2 weeks after subarachnoid hemorrhage. Most morbidity and mortality occurs before this interval and is related to rebleeding and vasospasm. Obviously, operation performed later will not improve the outlook for the victims of vasospasm and rebleeding, although it does optimize surgical results for those who survive. In the pioneering days of aneurysm surgery, operation was usually performed as soon as possible to prevent rebleeding. This approach was abandoned by most due to the frightening postoperative mortality and morbidity. In recent years, there has been an increasing awareness of the difference between the improvement in surgical results and the lack of improvement in overall management results. This has generated a resurgence of interest in early operation. Anecdotal reports of operation performed within several days of aneurysm bleeding using contemporary microsurgical and anesthetic techniques have generally been encouraging. Whether these findings, which are contrary to the notions entertained by most surgeons, are reproducible and generally applicable remains to be determined. This issue is currently being addressed by the International Cooperative Study on the Timing of Aneurysm Surgery. Until more information is available, early operation should be approached cautiously. Even so, increased emphasis must be placed on prompt diagnosis and early referral to neurosurgical centers of patients with aneurysmal subarachnoid hemorrhage. (Neurosurgery 10:514-519, 1982