Prevention of Vasospasm by Removal of Subarachnoid Blood in Early Operation

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Abstract
This prospective study was undertaken to objectively assess the feasibility of prevention of vasospasm by removal of subarachnoid blood in early operations by means of pre and postoperative CT scans. During the past 3 years, 181 patients with ruptured aneurysms were operated on. Among these, 64 cases with a single rupture and without intracerebral hematoma (except one case of temporal lobe hematoma) underwent direct operations within 4 days after hemorrhage. CT scans were performed on the day and the day following the operation. Localization and grading system of CT-visualized subarachnoid blood followed Fisher's classification. The clinical condition of the patients was graded according to Hunt and Hess's classification. All aneurysms were approached through a frontobasal lateral route and the side of approach was determined based on CT findings to remove the subarachnoid clot as much as possible when high density (HD) (which indicates a collection of blood) in the subarachnoid space was visualized on preoperative CT. Postoperative angiography was performed between day 6 and day 15 (the day of hemorrhage was day 0) because the symptomatic vasospasm usually occur between day 6 and day 15 after hemorrhage. Bilateral carotid system was studied. Only motor weakness associated with angiographic vasospasm was considered as ischemic symptoms due to vasospasm. It was possible to remove the subarachnoid clot in 90% of cisterns as follows: basal frontal interhemispheric fissure, bilateral Sylvian stems, Sylvian cisterns and the anterior part of insular cisterns, but it was impossible in frontal interhemispheric fissures and the posterior part of insular cisterns. Angiography revealed no spasm or mild spasm in the site where the clot was successfully removed and no ischemic symptoms or transient ischemic symptoms developed. Permanent symptoms due to vasospasm occurred in 8 patients in whom the subarachnoid clot remained on postoperative CT scans, mostly in the frontal inter hemispheric fissure, contralateral insular cistern and ipsilateral posterior part of the insular cistern where clots could not be romoved. Only one patient in Grade IV died due to vasospasm and excellent results(which indicates those who were able to return to their usual social life) were obtained in 100% in Grade I, 84% in Grade II, 85% in Grade III, and 15.5% in Grade IV. Our experience discloses that early surgery affords an opportunity to remove much of the blood from the subarachnoid space and that it perhaps minimizes the development of vasospasm.

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