Intra-operative premature rupture of the cerebral aneurysms. Analysis of the causes and management

The causes and management of intra-operative premature rupture are analysed and discussed. During the past 6 years, the authors, performed 398 consecutive direct surg ical interventions for ruptured cerebral aneurysms. Intraoperative prematur e rupture is defined as a rupture which occurs before the securing of the p arent arteries or the neck of the aneurysm and is out of control, at least temporarily. The causes and management were retrospectively analysed by rev iewing video tape recordings. Intra-operative premature ruptures which met the above definition occurred in 24 cases (6.0%). The causes were as follows: 1.) dural opening and arach noid opening (8.3%), 2.) haematoma removal (12.5%), 3.) brain retraction (1 6.7%), 4.) aneurysm dissection (62.5%). A double suction technique was used to control bleeding and haemostasis with a small piece of cotton or a temp orary clip, performed in 20 cases (83.3%). However, in cases with premature rupture immediately after the dural or arachnoid opening, the extension of the haematoma into the subarachnoid space resulted in severe brain swellin g and partial resection of the brain had to be done to secure temporary cli pping. The double suction technique and primary haemostasis using a small p iece of cotton or temporary clip resulted in good outcome even in cases wit h premature rupture. However, very early premature rupture also occurred al though its incidence was extremely rare. The removal of part of the brain c an secure the working space but the outcome was poor.