Abstract
Techniques for surgical treatment of subarachnoid hemorrhage in the acute stage have recently been developed. But problems still exist in the treatment of aneurysms in the posterior circulation. This paper identifies the cause of the inoperability in patients with basilar aneurysm and its outcome. We have treat 145 cases of basilar aneurysm and we studied 44 cases without direct operation among the 145 cases. The most common reason for not operating on the basilar aneurysm is the rerupture of the aneurysm. Thirty-seven cases (84%) showed subarachnoid hemorrhage from a basilar aneurysm. Rerupture of the basilar aneurysm was observed in seven patients (46%) and this caused the patient to deteriorate. Sixteen patients (96%) died following rerupture of a basilar aneurysm. Only one patient survived but in a vegetative state. Three cases with acute hydrocephalus showed rerupture of the aneurysm directly after ventricular drainage. The second common reason for not operating was severe primary damage due to the first subarachnoid hemorrhage. Nine cases (20%) were too damaged to be operated on, and their outcome was poor. Only one patient recovered almost completely, while others died due to primary subarachnoid hemorrhage. Six cases was not operated on because of the severe complication of age or position of aneurysm. All except one of these cases showed good outcome. Five cases (11%) was not operated on because of severe vasospasm. Problems such as rerupture of aneurysm, primary brain damage following subarachnoid hemorrhage, and vasospasm originate from the first attack of subarachnoid hemorrhage. Rerupture of the aneurysm might be decreased by direct operation in the acute stage. Vasospasm following the attack of subarachnoid hemorrhage might be prevented if the clot of the subarachnoid hemorrhage was removed in the acute stage. Volume expansion, induced hypertension, calcium antagonist or other treatment may decrease the ischemic deficit from vasospasm if direct operation for the aneurysm is performed in the acute stage. Though the high risk of aneurysmal surgery in the acute stage must be recognized, it is worth trying the operation in the acute stage for the treatment of acute hydrocephalus, rerupture, and vasospasm. Two to three percent of unruptured aneurysms per year showed subarachnoid hemorrhage and we heve showed the outcome of unruptured aneurysm surgery is good. It is difficult to decide to operate for an unruptured basilar aneurysm. But we must give more careful consideration to the operation of unruptured basilar aneurysms than to supratentorial unruptured aneurysm. Our results indicate that rerupture of ruptured basilar aneurysms was frequent and the outcome was poor. Direct operation for ruptured basilar aneurysms should be considered in selected patients to prevent rerupture of the aneurysm, vasospasm following an attack of subarachnoid hemorrhage or acute hydrocephalus.
