Subarachnoid Hemorrhage—Factors in Prognosis and Management

Abstract

A CONSIDERABLE diversity of opinion exists concerning the management of subarachnoid hemorrhage and of its principal cause, ruptured intracranial aneurysms. Moreover, that the controversy transcends disciplinary boundaries is illustrated by the conclusions of McKissock et al. ~-35 thatthe untreated appear to fare as well as those operated and that there can be no proof of the value of surgical treatment in this condition. ''3a Benson ~ concluded that if those patients who terminate fatally in the early danger period are excluded, conservatively treated aneurysms and surgically treated aneurysms have nearly the same prognosis. Yet many reports 1,1~176 have emphasized the poor outlook offered by conservative management, and the advocates of surgical therapy a r e many. 5,9,14Ag,2a,25,31,as,42,45'5~ Among the proponents of surgical therapy, however, the relative merits of different therapeutic approaches are contested. Direct attack, 39,42,52 as in clipping 9 or reinforcement 5~ of the lesion, is recommended by some, while others prefer indirect measures, 2,6,s,~6,2s,29,46 such as ligation of the carotid artery in the neck or trapping procedures. The timing of surgical intervention also evokes controversy . 12Ag,22,3~ Norl~n and Olivecrona 39 concluded that direct attack upon the lesion or ligation of the carotid artery in the neck was extremely dangerous during the acute phase of the illness and advised delay of surgical intervention until after the third week of the acute illness; Pool 42 recommended that direct surgical attack should be carried out between the 7th and 9th day after the initial hemor-