A step-by-step reflection on managing a complex aneurysm rupture
The patient arrived at the emergency department of a tertiary centre in western Sydney in the early hours of the morning, brought in by family after a sudden collapse at home. Within minutes of triage, the clinical picture suggested an aneurysmal subarachnoid haemorrhage: a thunderclap headache, a rapidly declining conscious state, and vomiting. The team mobilised immediately, securing intravenous access, drawing baseline bloods, and arranging an urgent non-contrast CT of the brain.
Complex aneurysm ruptures rarely present in isolation. This case involved a middle-aged patient with hypertension and a long smoking history, factors that increase the risk of intracranial aneurysm formation and rupture. The Australian public hospital system handles such emergencies through well-rehearsed stroke and neurosurgery protocols, but the geography of the country means that rural and remote patients often arrive delayed, having been stabilised and transferred by retrieval teams from regional centres.
This reflection walks through the clinical reasoning and technical steps that shaped the management of that night. It is not a textbook protocol but a candid look at how decisions unfolded when the diagnosis, the imaging, and the surgical field did not behave exactly as expected. The goal is to share the thought process honestly, so that trainees and colleagues can see how evidence, experience, and instinct intersect in the operating theatre.
| Approach | Invasiveness | Durability | Best suited for | Recovery profile |
|---|---|---|---|---|
| Surgical clipping | Open craniotomy with direct exposure | High long-term occlusion rates | Complex morphology, branching vessels, giant aneurysms | Longer ICU and ward stay |
| Endovascular coiling | Minimally invasive via femoral access | Risk of compaction or recurrence | Posterior circulation, elderly, poor surgical candidates | Shorter initial recovery, requires follow-up imaging |
Initial assessment and the race against time
The first hours after an aneurysmal rupture dictate the trajectory of the entire admission. Our patient was intubated by the anaesthetic registrar in the resuscitation bay, and a rapid sequence induction was performed to protect the airway as the Glasgow Coma Scale score drifted below eight. Pupils were equal and reactive, a small mercy given the impending risk of raised intracranial pressure and uncal herniation.
A non-contrast CT confirmed the suspicion: diffuse subarachnoid blood with a thick layer in the basal cisterns, Fisher grade 3. The next step was a CT angiogram to identify the culprit lesion and define its anatomy. In Australian tertiary hospitals, this pathway is streamlined, but it depends on having interventional neuroradiology available on site or within a retrieval network. Our centre has both surgical and endovascular capability, which influenced the subsequent conversation about treatment strategy.
Communication with the family happened in the small quiet room adjacent to the ED, a familiar setting in Australian hospitals where relatives receive life-changing news. The consultant on call explained the diagnosis, the risks of rebleeding, vasospasm, and hydrocephalus, and the potential treatment paths. Consent for surgery was obtained while the theatre team was preparing the operating room and the cell saver.
Imaging, grading, and choosing the right path
CT angiography revealed a 12-millimetre irregular aneurysm at the junction of the anterior communicating artery and the A1 segment, projecting posteriorly and partially thrombosed. The morphology was not ideal for simple coiling: a broad neck, incorporated branch vessels, and daughter sac features that raised concern for recurrence if treated endovascularly alone.
A multidisciplinary discussion took place between the neurosurgical team, the interventional neuroradiologist, and the intensive care consultant. In hospitals across Australia and New Zealand, such case conferences are standard, often guided by frameworks from the Neurosurgical Society of Australasia. The question on the table was whether to proceed with surgical clipping or attempt a stent-assisted coiling procedure.
The decision favoured surgical clipping for several reasons. The patient's age and the durability of surgical repair favoured open treatment, the aneurysm morphology was amenable to clip reconstruction, and the need to manage potential intraoperative haemorrhage directly aligned with an open approach. The comparison above summarises the general trade-offs between the two modalities, though every case demands an individualised assessment based on anatomy, comorbidities, and available expertise.
The surgical approach and intraoperative strategy
The patient was taken to theatre within six hours of presentation, a timeline consistent with Australian guidelines recommending early securing of ruptured aneurysms to reduce rebleeding risk. A standard pterional craniotomy was performed, with the patient positioned supine and the head rotated to optimise exposure of the anterior circulation and the suprasellar cistern.
Intraoperatively, the aneurysm was found to be densely adherent to the surrounding optic apparatus and the recurrent artery of Heubner. Dissection required patience, working through the clot from the frontal lobe side and decompressing the sylvian fissure widely. Temporary clipping of the proximal A1 was used for four minutes to soften the sac and allow final clip application without tearing the neck.
When the permanent clip was applied, an intraoperative rupture occurred, a not uncommon event in complex cases. Controlled suction, careful tamponade, and a second clip across the neck secured the bleeding. Indocyanine green videoangiography confirmed complete occlusion of the aneurysm and preservation of the adjacent A2 segments and the anterior communicating complex.
Intraoperative neuromonitoring, including somatosensory and motor evoked potentials, remained stable throughout the dissection and clipping. The decision to use temporary clipping and to manage the rupture directly rather than aborting the procedure reflects a philosophy of careful preparation and decisive action when the unexpected happens at the operating table.
Postoperative care and navigating complications
The patient was transferred intubated to the neurosurgical intensive care unit, where the team initiated standard post-rupture care: nimodipine for vasospasm prophylaxis, invasive blood pressure monitoring, and hourly neurological assessments once sedation was weaned. Transcranial Doppler was used daily to monitor for vasospasm, a critical concern in the days following the bleed.
On day five, the patient developed mild right-sided weakness and increasing confusion. CT perfusion and angiography confirmed vasospasm in the left middle cerebral artery territory. The interventional team performed an intra-arterial verapamil infusion and angioplasty, a procedure available in most major Australian tertiary centres but requiring careful coordination between neurology, radiology, and intensive care.
Rehabilitation began early, with input from physiotherapy, occupational therapy, and speech pathology, the multidisciplinary approach that defines modern stroke and aneurysm care in this country. The patient spent two weeks in hospital before being transferred to a rehabilitation facility, with follow-up arranged through the outpatient neurosurgery clinic at three months and again at twelve months to monitor for shunt-dependent hydrocephalus.
Lessons that travel beyond a single case
Several reflections emerge from this case that apply beyond a single operating list. The value of a pre-rehearsed protocol cannot be overstated. The team knew who to call, where the theatre was, and how to communicate with the family because we had practised the pathway before during simulation drills and previous cases.
Morphological complexity demands respect. Time spent studying the imaging, reconstructing the anatomy in three dimensions, and discussing options pays dividends in theatre when the dissection becomes difficult. Intraoperative rupture is not a failure but a known possibility, and the ability to manage it calmly relies on having discussed contingencies beforehand and on maintaining situational awareness during dissection.
The postoperative journey is as important as the operation itself, and the Australian system's emphasis on rehabilitation, community follow-up, and long-term neuropsychological support makes a tangible difference to functional outcomes. For trainees reading this, the message is to expect the unexpected, to plan for it, and to seek guidance when the anatomy or the patient's physiology does not match the textbook.
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