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Management of the ruptured intracranial aneurysm-early surgery, late surgery, or modulated surgery?

Personal experience based upon 468 patients admitted in two periods (1972–1984 and 1985–1989)

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Summary

The management of the ruptured intracranial aneurysm is studied in two consecutive series: an earlier series, including 328 patients admitted from 1972 through 1984, for which the general attitude was delayed surgery, and a later series, including 140 patients admitted from 1985 through 1989, in which selected patients were submitted to early surgery and other patients were postponed for delayed surgery, according to two main parameters: the clinical status and the patient's age.

When we compare both series, the overall management results demonstrate an improvement of 10% of satisfactory results and a decrease of 10% in the death rate in favour of the later series; for the surgical results, the figures are respectively 6% and 5% in favour of the later series. The relationship between age and outcome shows a considerable improvement: over 50 years of age, we observed plus 25% of satisfactory results and minus 22% in death in favour of the later series. Similarly the relationship between state of consciousness and outcome, demonstrated a great improvement; for drowsy and stuporous patients the figures are respectively plus 22% and minus 21% in favour of the later series.

When we consider the later series alone, the patients were admitted at 4 intervals of time from SAH (D0-3, D4-6, D7-15, D16 and over). The most favourable outcome was observed for those patients admitted late (after D7) and already stabilized. Patients admitted early (D0-3) were operated on at four intervals of time (D0-3, D4-6, D7-15, D16 and over). The most favourable outcome was observed for those patients operated on early (D0-3) or very late (D16 and over). For patients admitted early and being under 50 years of age, the results were: satisfactory 92%, poor 2.5%, death 5%. The relationship between age and outcome shows a very small difference between patients under or over 50 years of age. The relationship between level of consciousness and outcome still demonstrates an appreciable difference: plus 22% (satisfactory) and minus 7% (death) in favour of alert patients.

Rebleeding was the cause of disability or death in 2.8% of the overall later series and 2.7% of patients admitted early; as for vasospasm the figures are respectively 4.2% and 5.4%. These results are presented with reference to those of the Co-operative Study.

After this experience, the author's general attitude for the timing of surgery is neither systematic early surgery, nor systematic delayed surgery, but modulated surgery, based upon the evaluation of the operative risk: minor risk, major risk, intermediate risk. Schematically the authors propose: early surgery in alert patients and under 50 years of age (minor risk), late surgery in patients with disturbances of consciousness and over 50 years of age (major risk); preferably early surgery in younger patients even with disturbances of consciousness (intermediate risk); preferably late surgery in older patients, even being alert (intermediate risk).

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Authors and Affiliations

  1. Faculté de Médecine Alexis-Carrel, Lyon, France

    R. Deruty, C. Mottolese, I. Pelissou-Guyotat & J. F. Soustiel

  2. Hôpital Neurologique, Lyon, France

    R. Deruty, C. Mottolese, I. Pelissou-Guyotat & J. F. Soustiel

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  1. R. Deruty
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  2. C. Mottolese
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  3. I. Pelissou-Guyotat
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  4. J. F. Soustiel
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Deruty, R., Mottolese, C., Pelissou-Guyotat, I. et al. Management of the ruptured intracranial aneurysm-early surgery, late surgery, or modulated surgery?. Acta neurochir 113, 1–10 (1991). https://doi.org/10.1007/BF01402107

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