The effects of subarachnoid clot evacuation for the prevention of vasospasm (Vs) in the acute stage were reported previously at the 11th Conference of Surgical Treatment of Stroke in 1982, and complications due to excessive brain compression were pointed out when extensive clot evacuation was applied to the angry, swollen brain. In this paper, incidence of Vs demonstrated by angiography, neurological signs (NS) due to symptomatic Vs and low density area (LD) on CT scan which indicated ischemic infarction due to Vs was studied and compared with that of the previous report which dealed with 121 cases from 1976 to 1981.
Materials were 71 cases of ruptured aneurysm who were admitted within 3 days after the onset of subarachnoid hemorrhage (SAH) from 1982 to 1984. CT scan and angiography were followed for evaluating Vs and LD. Cases of intracerebral hematoma, troubled operation, moribund appearance and more than 70-year-old were excluded. In 12 cases out of 24 who revealed NS, neurological deficits disappeared at the time of leaving hospital. One case died of brain swelling with herniation due to Vs. The incidence of Vs, NS and LD were 85%, 34%, and 17%, respectively in this study. Vs and NS did not reveal definite changes, but LD revealed definite decrease, compared with the previous results of 80%, 39%, and 26%, respectively. The severer the degree of SAH, the higher the incidence of Vs, NS, and LD. On the other hand, the more marked SAH, the more decrease NS and LD. These results would indicate that the present policy for the treatments of SAH has been reasonable.
In the acute stage of SAH, sedation after neurological short evaluation and control of blood pressure should be performed preoperatively for the prevention of rebleeding attacks. Aneurysmal operations should be carried out as soon as possible if better prognosis was expected, especially in severer cases. Minimal brain retraction and sharp dissection could be the most important principle in the operations, and subarachnoid clots could be evacuated under minimal brain compression not to worsen brain conditions. Therapy with hypertension, hypervolemia and administration of dehydrates, Ca++ antagonist etc is performed in the early postoperative stage, and will have an effect on symptomatic Vs.
The incidence of brain infarction following Vs decreased as a result of (1) advancement in the operative procedures with the most important principle of minimal brain retraction and sharpdissection, and (2) treatment or prevention of symptomatic Vs in the early postoperative stage.
