In the present era, neck ligation or clipping of the intracranial aneurysm in the late stage has been successfully performed. On the other hand, however, as far as the case in the early stage is concerned, the surgical results were so grave that even an agressive neurosurgeon has hesitated to do perform the direct attack in such cases. In order to get an excellent result, the things which the surgeons are really eager to know is which factors have to be analysed before considering the surgical maneuvers.
In this publication, 1. The classifications of the preoperative severity so far published have been critically analysed; 2. Causes of the death due to the ruptured intracranial aneurysm have been investigated in the autopsy materials in the literatures; 3. By means of the clinical experiences in addition to the above mentioned autopsy findings, the intracranial pathophysiological changes have been schematically depicted in Fig. 1 and 4. Lastly, the possible factors related to the surgical risk were picked up as many as possible. Also the trial of establishing an ABC-Index (Index for Aneurysmal Basic Conditions) has been mentioned which would be possible to be treated by a computer.

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While accurate diagnosis depend on cerebral angiography, the first steps for early detection of ruptured intracranial aneurysm is a circumstantial clinical history. Although the observations of short dated course after are important, differences of opinion concerning the acute phase after onset of subarachnoid hemorrhage still present.
In this paper, from a view point of changes in clinical signs and symptoms, a term of so called acute phase in these cases of ruptured intracranial aneurysm was studies.
One hundred twenty five patients with ruptured intracranial aneurysm admitted to Keio University Hospital and its affiliated hospitals comprise the substance of this study. Articles of observations were following: headache, states of consciousness, meningeal irritation symptom, mental disorders, hemiparesis and findings of the ocular fundi.
Final conclusions cannot be drawn from results of analysis of clinical course in 125 patients. However, it may be strongly suggested from angle of clinical signs and symptoms that the term of acute phase signifies one week duration after rupture. Further studies into this problem are necessary.

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Microsurgery is very useful for direct operation of intracranial aneurysms due to its good illumination and magnification.
Our experience of 126 cases of direct microsurgical operations of intracranial aneurysms show that the operative mortality was 2.7% (3 deaths in 110 cases) in cases operated on later than the 8th day from the last subarachnoid hemorrhage (SAH) and that the mortality, however, was much higher in the earlier stage 37.5%-6 deaths in 16 cases). In the acute stage, the operative results were not always depending on the conditions (grades) of patients. 4 out of these 6 operative deaths die due to postoperative vasospasm and these cases were operated on just between the 4th and the 8th day from the last SAH. Examined 80 carotid angiograms which were performed on the cases of aneurysms within 3 weeks from last SAH and found that vasospasm of natural course appeared frequently after 6th day from the last SAH and were found earlier than 5th day from SAH. And therefore, patients died from postoperative vasospasm were probably disposed to vasospasm if any stimuli were given to them. On the other hand, cases operated on between 1st and 3rd day, all showed good results.
Microsurgery solved many technical difficulties in handling intracranial aneurysms and therefore, timing of operations aneurysm is now very important. If patients are in good conditions, operation are indicated as soon as possible. However, if patients are admitted between the 4th and 8th day from the last SAH, we think we had better postpone the operation after the 8th day. We try to prevent rebleeding by administration of Trasylol in this period.
Technical details of operations in the acute stage was also discussed.

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Surgical risk in intracranial aneurysm is primarily related to the patient's condition at the time of surgery. We are now employing the following modification of Hunt and Hess, one.
Serious systemic disease such as hypertension, diabetes, severe arteriosclerosis, chronic pulmonary disease, and severe vasospasm seen arteriography, are not, at least at present, concerned to this grading.

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127 cases of the intracranial aneurysm have been treated past three years.
Fifty-nine cases out of them have been admitted within seven days after onset, 32 cases within 24 hours, 17 cases within 3 days and 11 cases within 7 days.
Conservatively treated patients have shown the high mortality rate or recurrence followed by death (64.7%). The stalk ligation or clipping have performed in 14 cases within seven days after onset. Three cases out of them have died of the postoperative brain swelling or gastric hemorrhage.
Levels of consciousness after onset, angiospasm, timing of operation or indication in early surgical treatments of the ruptured aneurysm have been discussed herein in detail.

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The total number of the intracranial aneurysms experienced in our clinic was 434 cases until the end of December, 1970. In these cases, 385 cases were performed the intracranial direct operation and the surgical mortality rate during hospitalization was 7.8%.
A series of 107 cases as early operation cases, which direct operation was performed within 21 days after the episode of SAH were picked up.
The surgical mortality rate in early operation was definitively worse than in delayed operation, especially within 7 days. However, the period of operation was not the direct factor related to the operative result.
As to the operative results, the most important factor was the progress of state of patients consciousness.
Age, blood pressure, site of aneurysms, motor disturbance, cranial nerve disorder and preoperative vasospasm were not so important factors for the result of early surgical operation.
However, meningeal irritation and frequency of rupture of aneurysms were important factors.
Finally, as a policy for the management of ruptured intracranial aneurysms, we emphasize that the early direct operation for the intracranial aneurysms should be done positively, if the state of patients' consciousness is not in coma, or in a down hill course.

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According to the investigation of our series of 385 cases of the direct surgery of intracranial aneurysms, we have reported our policy about the decision of the timing of direct surgery after the last SAH, that the direct operation should be performed for ruptured aneurysm, even though the patient has severe vasospasm, if he is neither in coma nor in a down hill course of consciousness, even within one week after the SAH. However it seems that the extension of indication of direct operation for the ruptured intracranial aneurysms is our duty as a neurosurgeon. Recently, we applied the continuous ventricular drainage to 13 severe patients in the acute stage of SAH. 10 cases of them improved in their clinical condition after continuous ventricular drainage. The intracranial direct surgery within three weeks after the last attack were performed in 11 cases of 13 cases and its death in hospital was only one.
After all, continuous ventricular drainage to the severe patients in the acute stage after SAH, who were excluded from the surgical indication up to now, was very effective to level up the grade of patient's consciousness.
The clinical courses of those 13 cases were reported and the indication for the procedure of continuous ventricular drainage was discussed.

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A clinical significance of cervical sympathectomy in the treatment of the cerebral angiospasm showing manifest neurological deficit was discussed. The clinical series comprises 7 cases of ruptured intracranial aneurysms before and after direct aneurysm surgery. Cases were 25 to 63-y-o male and female patints with anterior communicating, uni or bilateral middle cerebral, internal carotid-posterior communicating aneurysm. The cervical sympathectomy consisted of perivascular sympathectomy of the cervical internal carotid and superior cervical sympathetic ganglionectomy of the ipsilateral side to the cerebral angiospasm.
Improvement of infarctic symptoms was observed in 6 cases of this series within 3 days after cervical sympathectomy, among them, within 7 hours in 2 cases and on the next day in another 3 cases. Angiographical improvement was also demonstrated on 2nd day. in 4 cases, 6th day in 1 case and 14th day in another remaining case. In these cases, angio-spastic cerebral infarction symptoms, such as hemiplegia, aphasia, psychiatric disorders or consciousness disturbance not only being persistent for over a week in spite of supportive treatment, but also rapidly developing severe one in a so-called early operation case of ruptured aneurysm seemed to be managed well by cervical sympathectomy. In the last case, cervical sympathectomy was done in advance far before appearance of cerebral infarctic signs. Nevertheless, ipsilateral cerebral angiospasm occured unexpectedly leading the patient to fatal cerebral nfarction. Some unsolved problems as to timing and limitation of the sympathectomy are still left behind. However, it can be said that cervical sympathectomy is one of the most effective treatment at present for the cerebral angiospasm developing infarction symptoms in clinical observation as well as in accordance with one of our co-workers, Dr. Sato's study on innervation of the human cerebral artery combined with physiological experiments.
Thus, this method is suggested in the treatment of various ischemic brain disorders induced by cerebral angiospasm. In such a case, it must be done as a first choice treatment before irreversible brain damage develops, as soon as cerebral infarctic sign appeared.

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Two cases of the persistent primitive hypoglossal artery associated with aneurysm have been reported.
Case 1. A 48 year-old woman ad mitt ed to our clinic with subarachnoid hemorrhage. Left carotid angiography revealed an aneurysm of the anterior communicating artery and the persistent primitive hypoglossal artery. Under the hypothermic anesthesia, the aneurysmal neck was ligated. About 1 month the operation, she left our clinic in good condition.
Case 2. A 34 year-old woman was admitted with subarachnoid hemorrhage. The right an giogram showed the persistent primitive hypoglossal artery with an aneurysm at its entertion into cranium. Under the hypothermia, the aneurysmal neck was directly ligated carefully avoiding the cerebral blood flow interruption of that artery. About 1 month after the operation, she was discharged in good condition.
We collected 59 reported cases of the persistent primitive hypoglossal artery including our two cases. Reviewing these cases, the symptoms and signs are related with other coexisting anomalous condition rather than persisting primitive hypoglossal artery itself. It is commonly found at a chance of medical examination suspecting intracranial lesions, such as aneurysms or brain tumors and so on. On the literature 6 cases of the intracranial aneurysm are reviewed in the 59 cases of this primitive artery with incidence of 10%.
Vertebral arteries are often hypoplastic or not visualized on angiograms. Thus it must be emphasized that preservation of the primitive hypoglossal arterial flow as a collateral circulation is necessary on the direct surgery for the accompaning aneurysm.

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We have reported a case of unruptured giant aneurysm of basilar artery of 15-year-old boy.
Though subtentorial tumor was suspected neurologically, the giant aneurysm was reveal-ed in his subtentorial region by vertebral angiography.
The neurologic symptoms of this patient were so progressive that the direct operation was performed, but he died unfortunately 14 days after the opetation and was autopsied.
At autopsy, the large spherical aneurysm which arose from trunk of basilar artery was demonstrated and was measured about 4.5cm in diameter.

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Recently, with the development of microsurgery surgical risk of intracranial aneurysm have become less.
That is, by selecting approach to aneurysm, some advantage are obtainable; the range of craniotomy become small elevation of the brain is minimized, temporary clipping of cerebral artery is, in principle, not necessary, leading to unnecessity of requirement for hypothermia. This means that direct surgery of aneurysm is possible in acute cases after hemorrhage.
Recently I have performed direct surgery of intracranial aneurysm on 8 cases with preoperative existed disturbance of consciousness in acute phase.
By acute case, a large frontotemporal craniotomy was performed, the bone flap was removed and the dura was patched with the artificial dura for an exernal decompression. Also, if necessary, an internal a decompression was performed.
In acute patient, a temporary clipping to the parent vessel was not used in order to avoid postoperative vasospasm. Regarding to the case with preoperative vasospasm, the use of hypotension is not desirable, because it may enhance circulatory disturbance.
A neck clipping could be carried not all 8 cases under microscope. Some surgical findings in acute cases were demonstrated by monitoring in a 16mm film.
It is most desirable to treat arterial aneurysm as soon as possible at an early stage and perform decompression for unconscious patient, and then to throughly cope with cerebral edema and vasospasm.

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In the majority of patients suffering spontaneous subarachnoid hemorrhage, cerebral angiography is a safe and essential diagnostic procedure. Rupture of an intracranial aneurysm during angiography is very rare. A case of rupture of intracranial aneurysm during angiography is presented. Carotid angiograms showed extravasation of contrast material in the subarachnoid space of the base of the brain. The literature was reviewed and possible mechanisms were briefly discussed.

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Arterial spasm in a case with ruptured aneurysms was observed by repeated angiography. The degree and location of arterial constriction was different on each angiogram. This fact means that arterial spasm is not stable on a certain artery, but has a tendency of dynamic changes. This is very important when we discuss the significance of vasospasm in relation to operative result.

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A case of 57-year-old widow with multiple, at least 18, intracranial aneurysms which were presumed to be mycotic ones was reported. Symptom was initiated by subarachnoid hemorrhage manifested with abrupt severe headache, drowsiness and left sided hemiplegia. On admission 14 days after subarachnoid hemorrhage attack, leucocytosis with eosinophilia, positive C reactive protein and increased erythrocyte sedimentation rate were revealed. On the 15th hospital day, a gluteal sbdcutaneous abscess became manifest from which staphylococcus epidermidis was cultured. Lumbar puncture showed 150 mm H₂O of opening pressure and xanthochromic spinal fluid with pleocytosis of 150/mm³, containing lymphocytes of 94% and neutrophil lenkocytes of 4%, protein of 140 mg/dl, sugar of 38mg/dl, Cl of 118mg/dl (NaCl) and positive tryptophan but no culture. Plain skull films revealed 5 sites of open irregular semicircular calcification of 5 mm to 30 mm n diameter in the bilateral cerebral hemisphere. Right carotid angiograms showed 10 aneurysms of various size shape such as round of 3 mm in diameter or irregular fusiform of 5×14 mm at the peripheral portion of the anterior, middle and posterior cerebral arteries. Left carotid angiograms revealed 3 round aneurysms of 2 to 4 mm in diameter at the peripheral anterior -cerebral artery. No abnormality was pointed out on vertebral angiograms. Intracranial mass effect was thought to be negligible. A calcified aneurysm was extirpated from the right calloso-marginal arterial branch. Gross and histological examination of the specimen were done. In this patient, anctcedent infectious disease such as endocarditis, septicemia or meningitis which might cause mycotic aneurysms were not pointed out. However, angiographical, surgical and histological features of the aneurysm were identical to mycotic one. The patient was discharged home not leaving behind the infectious sign or the neurological deficit except for slight weakness on the left upper and lower extremities. Clinical aspects of mycotic cerebral aneurysms were discussed with some review of literature.

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