We had performed radical operations on 152 patients with cerebral aneurysms during Jan. 1, 1969 to Dec. 31, 1972.
Sixty-eight cases were early operation cases, should we define early operations as those within 14 days after the last SAH.
Operative indication in the early stage of SAH is a controversial one. In our department the indication has changed gradually with accumulation of our operative experiences. At first, the early operation was indicated for all the patients with ruptured aneurysms except for the cases with decerebration. As supplementary methods, decompression procedure, washing out of ventricular and lumber C.S.F., or induced hypothermia etc, were tried during and following operation.
The results of our operations on 138 cases were as follows: operation within 7 days had poor results in spite of all effects above mentioned: Quality of C.S.F., and consciousness level had important effects upon the results of operation.
Our policy for operation of ruptured aneurysms was changed into the new one in Sept. 1972, when P.O.B, was tried clinically in our department.
1. Radical operation is indicated after 14 days of the last SAH.
Early operation is indicated on the following cases;
(1) with intracerebral or intraventricular hematoma, and with possibility of life-saving by evacuation of the hematoma (without radical procedure of the aneurysm).

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It is a well-known fact that the mortality rate of rebleeding in the case of the ruptured cerebral aneurysm is mu2h higher than that of the initial bleeding, but there remains many enigmas as to the reasons about it. On the other hand, the causes of so-called rebleeding have been considered to be 1) the re-rupture of the aneurysm, 2) the bleeding from the second one of multiple aneurysms, and 3) the bleeding from the concurrent cerebral or spinal disease e.g, brain tumor etc. ; among these, the re-rupture is generally presumed to be the most frequent.
We postulate that, as a cause of rebleeding other than these, the hemorrhagic infarction of the brain attributable to the vasospasm and or vascular stenosis after the initial bleeding is not uncommon and of greater importance in regard to the so-called rebleeding, and that the infarction encroaching upon the teritories of perforating arteries is the major cause of death. In other words, reappearance or increase in grade of the subarachnoid hemorrhage (SAH), which is usually called “rebleeding”, is the omnious sign of the life-threatening hemorrhagic infarction.
Since the direct operation for the cerebral aneurysm is almost perfectly established in the technical problem especially in the field of microneurosurgery, the cerebral vasospasm and infarction are the last and most important problems remaining to be resolved in respect to the treatment and prevention.

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Intentionally delayed surgical intervention to subarachnoid hemorrhage due to recently ruptured intracranial aneurysm certainly lessens morbidity and mortality. However, this kind of treatment with conventional.antifibrinolytic or other medical agents does also jeopardize patient's life expectancy in a case of recurrent bleeding. Between these two contradictory factors a surgeon should make his own choice of treatment to each case of subarachnoid hemorrhage in the early stage.
Eighty consecutive cases of intracranial aneurysm were treated with consistent policy that any patient should be operated on as soon as possible whenever surgery being indicated and following results were obtained;
1) Surgery for intracranial aneurysm which was performed within the first 10 days after subarachnoid hemorrhage should be termed “the early stage operation” and sustained significantly different meaning for patient's prognosis.
2) According to Hunt & Hess's classification Grade I to III patients could be operated in the early stage regardless the location of the aneurysm or past episodes of subarachnoid hemorrhage.
3) Internal carotid aneurysm could be operated even when carotid angiogram showed angiospasm.
4) In the case of anterior communicating aneurysm surgery should be refrained until 11th day when it was graded as III since mortality was markedly decreased after 10th day.
5) When patient remained in grade IV or V longer than 2 'weeks there was no sense to wait the timing of surgery and it was advised to perform surgery whenever patient showed evidence of recovering consciousness.

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So-called reattacks after subarachnoid hemorrhage due to rupture of intracranial aneurysms were analyzed. Tohoku University, Division of Neurosurgery has experienced 709 aneurysm cases by the end of 1972, and 113 cases found in 1972 were carefully documented in regard to the reattacks for this study.
The initial and subsequent reattacks were classified under the following criteria: 1) major bleeding, 2) moderate bleeding, 3) minor bleeding, and 4) cerebral infarction.
In 62 cases out of the 113 cases, reattacks occurred up to four times at an interval ranging from a few hours to 16 years. Within one month after the initial subarachnoid hemorrhage, 66 reattacks occurred in 52 out of above 62 casse.
Based on the analysis of these reattacks the following conclusions were drawn:
1. The reattacks tended to occur between the 2nd and the 14th day following the initial bleeding, the highest incidence being on the 7th day.
2. The reattack may be either rebleeding or infarction, however, the latter was more common within 14 days after the initial hemorrhage.
3. When the initial bleeding was major or moderate, the reattack due to rebleeding occurred within first 3 days or after 15 days after the initial hemorrhage. On the contrary, the reattack due to infarction occurred exclusively in between 4th and 14th days period (which is known as predilection period for cerebral vasospasm) after the initial hemorrhage.
4. When the initial subarachnoid hemorrhage was minor, the rebleeding occurred at any time in the subsequent days, while reattacks due to infarction tended to occur also in the 4-14th day period.

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We have already proposed a constructive direct surgery of ruptured intracranial aneurysm in early state.
Some patients in good condition (Botterell gr. II-III) had a poor prognosis due to postoperative arterial spasm. In this study, we have reported the dynamic changes of vasospasm observed by repeated angiography, and clarified the significance of vasospasm in surgery of early stage.
Postoperative vasospasm frequently occurred in cases which had operation within 14 days after the last attack. The poor prognosis was obtained in the cases with diffuse vasospasm in pre- or postoperative angiograms.
In conclusion, when marked subarachnoid hemorrhage was observed at the time of operation, external decompression and ventricular drain-age are preferable for the brain edema due to postoperative vasospasm. If preoperative angioframs showed diffuse vasospasm, the delayed operation was advisable under constructive conservative management including the continuous ventricular drainage.

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The authors reported the clinical results of the application of the ventricular drainage to the patients suffered from acute or subacute hyperintracranial pressure caused by ruptured intracranial aneurysms.
Concerning the patients with ruptured aneurysms we have a prototype of the methods of treatment as follows:
(1) After admission to the hospital all patients are isolated in ICU and they are under mild sedation with either parenteral or oral administration of barbiturates or minor tranquilizers.
(2) If hypertention could not be lowered by the above mentioned treatments, reduction of blood pressure is attained by the administration of appropriate amounts of antihypertensive drugs such as chlorthiazide or methyl dopa (Ransohoff).
(3) Antifibrinolytic agents such as trans-AMCHA (at least 10gm/day) are administered intravenously or orally to all patients. (Mullan).
(4) Evacuation of intracerebral hematoma is urgent if angiographic study revealed the presence of hematoma.
(5) In principle, direct surgical treatment of aneurysms is intentionally delayed until patients recover to Grade I or II under conservative treatment.
In this series, we have 10 cases of the ruptured aneurysm without hematoma. All of these patients developed moderate or marked increased intracranial pressure with or without internal hydrocephalus.
According to the classification originally designed by Hunt and Hess these patients belonged to Grade III and IV. Ventricular drainage was carried out to all of these patients utilizing either V-P or V-A shunt.
It has been known that immediate benefit of the shunt-operation was the improvement of nuchal rigidity within 2 to 3 days after surgery. Consciousness level and other neurological signs started also to improve within a week thereafter. As soon as neurological status became improved, reexamination of angiography was performed in several cases. It is only our impression that when patients showed improvement of neurological symptoms, angiospasms seen in angiogram were improved comparing with our other cases experienced formerly.
In the limited number of our series presented here, no deteriorative complication such as rerupture of aneurysm occurred during and after surgery.
Finally we should mention our experimental study on the dogs concerning the correlation between intracranial pressure and blood pressure of circle of Willis. High intracranial pressure was produced by cerebral compression induced by inflating epidural balloon. In this situation,if intracranial pressure lowered by deflating balloon, simultaneous reduction of blood pressure in circle of Willis occurred.
This seemed to be reflected by the reduction of peripheral vascular resistance of cerebrum after the deflation. According to these experimental results, it seems that reduction of intracranial pressure by ventricular drainage in cases of subarachnoid hemorrhage may have similar effect to the cerebral vascular hemodynamics of the patients. That is, this surgical intervention might not evoke the possibility of rerupture of aneurysms.

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The patients of ruptured intracranial aneurysm admitted to the Okayama University and affiliated hospitals have been reviewed. Among 250 aneurysm cases, 91 were admitted within 3 weeks since the last hemorrhage, and 84 suitable patients were included in this study, excluding 5 cases of incomplete statement and 2 cases of deaths evidently caused by surgical technical failure.
A new trial of grading of risk has been made in those 84 patients of ruptured intracranial aneurysm. As Grades from I to V of Hunt et al. are most commonly used, the authors' grading method is also based on those of Hunt, and the prognostic factors are limited to those obtainable from bedside neurological examination. Those factors are so lined up as to form a shaft of 'GOD MAN Dis. Course', which may conveniently be used for determination of clinical conditions and risks of ruptured aneurysms as a more detailed grading.

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A score table has been derived from 138 cases of intracranial aneurysm whereby the timing of the operation can be determined in each patient. Among the factors that were considered to influence on the fatal rebleeding, sex, age, location of aneurysm, frequency of the episode of bleeding (static factors), cerebrospinal fluid pressure, level of consciousness, angiospasm, angiographical signs of hematoma, and blood pressure (dynamic factors) were compared between non rebleeding group and rebleeding group in 48 cases of ruptured intracranial aneurysm which were transferred to our service within 2 weeks after the recent episode of bleeding.
We evaluate the state of each patient according to the score table. A patient calculated the total score more than 13 is presumed to rebleed within 1 to 5 days following admission, on the other hand, a patient calculated the total score less than 9 is expected little chance of rebleeding under careful management. The former should be operated as soon as possible and the latter could be operated after improving the unfavourable factors. The case calculated between 10 and 12 should be observed carefully on dynamic factor (blood pressure, etc.) until the patient was classified the former or the latter. The validity of the score table has been demonstrated in illustrated cases. This is a preliminary study and further evaluation with a larger series will be required to validate this socre table.

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A 64-year-old female was admitted to the hospital on October 12, 1972. On October 11, the patient lost suddenly her consciousness for about 4 hours. Because of severe headache after regaining consciousness, she was admitted to a hospital. Spinal tap disclosed bloody CSF with opening pressure of 300mm H₂O
On admission the patient was clear. Carotid angiographies revealed symmetrical aneurysms of the middle cerebral artery, the right one being interpreted as ruptured one. Because of lowering her conscious level on the following day, direct attack was performed. At first the right temporal cranitomy was done and the ruptured aneurysm was successfully clipped. It took five and a half hours in consequence of careful dissection of the aneurysm in order to preserve the small perforating arteries. And then the unruptured aneurysm was clipped through the left temporal craniotomy. It took two hours. The patient did not awake from the anesthesia. Postoperative right carotid angiography demonstrated evidence of intracerebral hematoma in the temporal lobe. Through immediate recraniotomy 20 gm of intracerebral clot was evacuated. The right frontal lobe was removed owing to acute brain swelling. On the postoperative 3rd day recraniotomy was performed again because of developing anisocoria. Intracerebral hematoma was again removed, but hemostasis was extremely difficult because of oozing hemorrhage from the brain. The patient did not regain consciousness and died on October 16.
There are 37 cases of multiple aneurysms (24%) in 152 cases of intracranial aneurysms encountered in our department. Our surgical policy for multiple aneurysms was early, one stage operation.However, when the ruptured side operation is time-consuming as shown in the present report, nonruptured aneurysm on the opposite side should be attacked separately in near future.

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A case of a 42-year-old male with 5 intracranial multiple aneurysms at the anterior communicating artery, bilateral middle cerebral arteries, right internal carotid artery and junction of the left internal carotid and posterior communicating arteries is presented.
This case had a recurrent hemorrhage due to rupture of previously unruptured aneurysm at junction of the left internal carotid and posterior communicating arteries about 3 years later after treatment of ruptured aneurysm at the anterior communicating artery.
This case was cured by direct intracranial operation at two times without neurological deficits.
Our policy for the treatment of intracranial multiple aneurysms is that all aneurysms should be treated by intracranial direct operation at one time as far as possible.

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A case of multiple intracranial aneurysms was reported. Their locations were the right pericallosal artery and the left vertebral artery. The patient died from the second attack of subarachnoid hemorrhage.
A 48-year-old male had an attack of subarachnoid hemorrhage on July 21, 1972 and he was admitted to the Toranomon Hospital on July 24, 1972.
Neurological findings: He was drowsy and confused with stiff neck, and showed motor weakness of right upper extremity and left lower extremity. Babinki's was positive on the right side. Fundi oculi showed papilledema and pre-retinal hemorrhage.
Among these neurological findings, we considered that motor weakness of the left lower extremity was worthy mentioning. Then, right carotid angiography was performed, and a small arterial loop was found at the right peripheral pericallosal artery. But, as a results of repeated angiography, it was diagnosed a saccular aneurysm. During 4 vessel study, we found another saccular aneurysm arising from the left vertebral artery at the junction of the posterior inferior cerebellar artery. However, we considered that the initial rupture of aneurysm was that of pericallosal artery, mainly from the neurological findings.
As the level of consciousness was recovering gradually, we were preparing the direct attack to the aneurysm of the pericallosal artery. But he had the second attack of the subarachnoid hemorrhage and rapidly died on September 9, 1972. Autopsy showed the rupture of vertebral aneurysm. No rupture of the pericallosal aneurysm was confirmed.
-Conclusion-
(1) At the acute stage of ruptured intracranial aneurysm, we must evaluate the neurological symptoms, when they exist.
(2) when the location of angiographically detected aneurysm does not explain the neurological symptoms, we must perform a complete 4 vessel study.

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There are many specific aspects as for the operative intervention. the operation timing and the decision of the ruptured aneurysm for the double aneurysms. The operative procedures applied in our 42 cases of double aneurysms were as follows; direct neck clipping in 27 cases, clipping and reinforcement coating in 9 cases, coating only in 5 cases, Selverstone cervical carotid ligation in 2 cases and hematoma removal or decompression in 3 cases.
CASE #1 K.H. 24 y/o male.
Referred to our neurosurgery 4 days after the onset of paroxysmal bitemporal severe pulsating headache. Severe meningeal signs with nuchal rigidity,however, there is no neurological laterality (Hunt grade II). CSF was xanthochromic with very high pressure (not measured). Panangiography revealed an aneurysm at the anterior communicating artery which was clipped by Scoville clip via right frontotemporal craniotomy on the 6th admission day. Postoperative angiography revealed adequate clipping of the neck with minimal bowing of the anterior cerebral artery from right to left. Repeated angiography 2 weeks after the operation disclosed ANOTHER different shape aneurysms at A-1 and A-2 junction. It was confirmed as a newly formed aneurysm at the second operation. It appeared to be just distal to the Scoville clip applied in the previous operation. The second operation showed that the previous Scoville clip was not slipped off. Final angiography reveals perfect disappearance of the second aneurysm and the patient was returned to his original work on the 60th admission day.
CASE #II T.T. 48 y/o male.
Brought in to our neurosurgery on the 6th day after onset. Severe generalized headache was associated with persisting nausea and vomiting. Severe meningeal signs with nuchal rigidity and bilateral blurred discs without preretinal hemorrhage were noted on admission (Hunt grade III). Spinal tap showed xanthochromic CSF with 200 mmH₂O in opening pressure. Panangiography revealed a larger aneurysm in the trifurcation of the right middle cerebral artery and a smaller one in the anterior communicating artery. On the 7th admission day, the patient underwent right front-temporal craniotomy under normothermia which disclosed diffuse subarachnoid hemorrhage over the frontal lobe and in the Sylvian fissure. Neck clipping was done with week clip to the middle cerebral artery aneurysm at first by separating Sylvian fissure and careful procedure was carried out alongside with the very spastic anterior cerebral artery. However, the feeder artery was hard to detect due to severe vasospasm and coating with EDH-adhesive was applied to the anterior communicating artery aneurysm. Postoperative angiography showed perfect neck clipping of the trifureation aneurysm and perfect disappearance of the coated aneurysm. This case taught us that the operative approach in the double aneurysms should aim the ruptured one at first. The patient was back to his executive business work at present without any disability.
CASE #III M.A. 56 y/o male.
Transferred to our neurosurgery on the 3rd day after the onset. His status was semicomatose with left 3rd nerve palsy of moderate degree and severe nuchal rigidity (Hunt grade III). CSF was bloody(190 mmH₂O of opening pressure, 0.5 ml removed). Panangiograp y disclosed double aneurysms in the left pericallosal-callosomarginal bifurcation and in the anterior communicating artery. Careful separation of falx via the left front-temporal craniotomy under normothermia was proceeded. However, abrupt rupture occurred during dissecting the aneurysm vertex, which was controlled by sucker and neck clipping was done with Week clip. Anterior communicating aneurysm was clipped via different route. The patient became clear in consciousness on the 2nd POD and works as a farmer at present.

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The number of our cases with the intracranial aneurysm is 133, of which 17 cases (13%) are multiple intracranial aneurysms-lower percentage compared with approximately 20% reported by other investigators. If intracranial aneurysm which has not passed more than 7 days after the last rupture is defined as an acute stage of ruptured intracranial aneurysm, 6 cases of multiple intracranial aneurysms were operated at an acute stage.
As for acute cases of intracranial aneurysm after subarachnoid hemorrhage, we make it a rule to conduct surgical treatment as soon as possible by diagnosing intracranial aneurysm which is the bleeding source by means of cerebral angiography on the admission day. When there are no neurological focal signs or there are signs suspected of aneurysm in the region of the left internal carotid artery, performed are left carotid angiography and right retrograde brachial angiography. When there are signs suspected of aneurysm in the region of the right internal carotid artery, both right and left carotid angiographies are conducted with the addition. of postoperative vertebral angiography. In all 6 cases all aneurysmal necks were clipped on the same day. The way to approach was as follows; frontolateral incision in the case at unilateral internal carotid artery and the anterior part of the circle of Willis, bilateral frontolateral cranitomies after coronal incision in the case at the bilateral carotid arteries, and atypical coronal incision in the case at the internal carotid artery and the distal part of anterior cerebral artery.
When the preoperative level of consciousness is in coma or semicoma, it is recommended to defer the operation of the non-bleeding aneurysm until the improvement of the consciousness after clipping of the ruptured intracranial aneurysm.
In the case of the operation of the ruptured intracranial aneurysm at an acute stage, the neck clipping of the aneurysm would be impossible without the microsurgical technique since the operative field is extremely limited.
The postoperative results indicated two cases of mental disturbance and one case of hemiparesis. Two patients, having intraventricular hematoma and G-I tract bleeding, respectively, died.

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The cooperative study showed an incidence of 19% for multiplicity of intracranial aneurysms. Nineteen cases with multiple aneurysms were found in 188 verified cases of intracranial aneurysm at Kyoto University Hospital from 1963 to 1972. The incidence was 10.1%.
Here, we are reporting recent three cases with multiple aneurysms, which were admitted in acute stage, i.e. within 14 days after the last hemorrhage.
In the first case, having AC and left MC aneurysms, operative technique was poor. The operation took too much time. The temporary clips were used under induced hypotension. The right A-1 and one of the left frontal opercular branches were occluded. Post-operative angiographies disclosed wide-spread vasospasm from C-2 to A-1-2 and M-1-2 on both sides. On the 12th postoperative day the patient expired.
In the second with AC and right MC aneurysms, operative treatment was not undertaken because the patient was moribund. Angiographies showed widespread spasm and intracarotid administration of 20 mg of POB gave no effect.
The third patient had had right common carotid ligation for right ICPC aneurysm in 1965. In October 1971, sudden onset of severe headache and exaggeration of right ptosis made the patient be readmitted. Right ICPC aneurysm was visualized through the left vertebral angiography. Right frontotemporal craniotomy and neck' clipping of the aneurysm were performed without any difficulty, and the patient was discharged on the 10th postoperative day. However, 8 days after discharge he suffered severe headache again, then became comatose, and died. Post-mortem examination revealed an unsuspected ruptured aneurysm at AC. Retrospective careful examination of the angiograms under second-order subtraction showed the presence of the AC aneurysm.

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