Surgery for ruptured vertebrobasilar aneurysms in the acute stage of SAH, when brains are more swollen, is considered to be difficult, since such aneurysms are deep-seated and surrounded by many important perforators, cranial nerves and vital structure. Therefore, delayed surgery is common for these aneurysms.
During the past 5 years, 11 cases with ruptured vertebrobasilar aneurysms have been subjected to delayed operation. The outcome was unfavorable because of a high rate of rebleeding (18%), vasospasm (36%) and hydrocephalus (64%). Recently we performed early operation on three patients (BA-SCA, BA bifurcation, VA-PICA), and the outcome was favorable.
Pre-, intra-, and post-operative management of vertebrobasilar aneurysms subjected to early operation is as follows:
A. Preoperative management
1. sedation and control of blood pressure: intravenous administration of pentazocine, oral administration of nifedipine
2. non-invasive examination digital subtraction angiography using non-ionic water-soluble contrast medium
B. Intraoperative management
1. marking“umbrella”shaped incision line on scalp
2. minimal brain retraction
1) mannitol
2) wide opening of Sylvian fissure
3) gradual removal of CSF
opening of basal cisterns opening of the lamina terminalis ventricular drainage
3. removal of subarachnoid clots
C. Postoperative management
1. cisternal drainage for two weeks
2. hypervolemic, hypertensive therapy for ischemic neurological deficits from vasospasm
In conclusion, early operation can be carried out without many problems for ruptured vertebrobasilar aneurysms.
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