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Intraoperative rupture of a cerebral aneurysm is not always controlled by anaesthesiological and surgical methods. Its frequency is about 7 to 36% of procedures. Prevention by induced hypotension is by itself a factor of morbidity since regional circulatory disturbances are issued from subarachnoid hemorrhage (hypovolemia, dysautoregulation, vasospasm...). Temporary clipping of aneurysm adjacent arteries is a feasible method of preventing rupture, also during microsurgical management of some dangerous localizations as anterior communicating artery or basilar artery. Clinical course improves with prepared clipping, early methods for cerebral protection, and preventing microcirculatory disturbances during occlusion and blood flow restoration. Unusual anaesthesiological means, hemodynamic and hemorheological supports are required for these purposes.

Morbidity after aneurysmal subarachnoid hemorrhages is proceeding from many factors; ischemic etiology is underestimated and frequently thought to be vasospasm related only. Other undoubted mechanisms are in the setting of ischemic disorders after ruptured aneurysms. The management of these disorders is relevant of new calcium blockers. Early administration of prophylactically oral nimodipine, with temporary intravenous administration of the therapy after surgery or in the setting of delayed ischemic deterioration, were assigned to 36 patients with aneurysm surgery. Efficacy was judged on prevention and outcome of ischemic disorders at discharge and three months later using the Glasgow Outcome Scale. On all, twenty-nine patients were disabled from any etiology; twenty made full or improved recoveries at discharge; twenty-eight get independent conditions of life at 3 months. Fourteen patients have return to their pre-rupture activity. Twenty-two surgical patients (61%) set an undoubtly ischemic disability during any time of their hospitalization, but many etiologies were identified in majority of cases. Spasm is the main factor of stroke in only 6 patients, and one of the ischemic factors in 15 cases. Among these ischemic deteriorations, twenty improved or made full recovery at discharge and get independent life at 3 months. No death with spasm. These data support the assumption that vasodilatating is not the only mode of nimodipine action. Hypervolemia must be adjunct with nimodipine to prevent regional hypoperfusion.

The authors report a case of an aneurysm of the posterior cerebral artery that was operated on after 28 weeks of amenorrhoea without any sequelae for the mother or the fetus. The article gives precise details of the neurosurgical procedures carried out in this pregnant woman and how and what neurosurgical anaesthesia was administered while the aneurysm was cured and the pregnancy continued. Finally the obstetrical and neurosurgical care is discussed. The neurosurgeons decided on the operation in view of the neurological findings. Once the neurosurgical decision has been made, the obstetrical procedures depend practically on the length of amenorrhoea. Briefly, we would suggest the following: before 31 weeks of amenorrhoea: curing the aneurysm and going on with the pregnancy; after 32 weeks of amenorrhoea: first to carry out a caesarean section and during the same operation to treat the vascular malformation.

The efficacy of intravenous Nimodipine (used at the rate of 2 mg.h-1) was investigated in the treatment of delayed ischemic deterioration or angiographic vasospasm after subarachnoid haemorrhage caused by a ruptured aneurysm in a randomized, double-blind, placebo-controlled multicenter study. A total of 127 case reports was validated: 73 patients received Nimodipine, 54 received placebo. The two groups were comparable in demographic and clinical status data. Analysis of number of deaths and of patients with severe deficit related to vasospasm alone showed a significant statistical difference (Nimodipine = 19%; Placebo = 49%; p = 0.01). The risk of mortality connected with vasospasm was reduced by 82% in the treated group. Side effects were equally frequent in the two groups. The only difference noted was the increase in heart rate in group Nimodipine. The results of this study demonstrate the efficacy of intravenous Nimodipine in the treatment of consequences of cerebral vasospasm after a subarachnoid haemorrhage caused by a ruptured aneurysm.