Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report

Summary Background. Blood clot evacuation through an osteoplastic craniotomy, a procedure requiring neurosurgical expertise and modern medical facilities, is the accepted method for treatment of a pure traumatic epidural haematoma following closed head injury. In certain emergency situations and/or in less sophisticated settings, however, use of this procedure may not be feasible. The present study was undertaken to ascertain whether placement of a burr hole and drainage under negative pressure constituted a rapid, effective and safe approach to manage patients with simple epidural haematomas. Methods. Thirteen patients suffering from a traumatic epidural haematoma were treated from January, 1999 to October, 2002. Twelve patients presented with skull fracture but no fracture was depressed. Placement of flexible tubes through a burr hole, followed by continuous suction under negative pressure, enabled aspiration of the clot and drainage of the cavity. In 8 cases, the procedure was performed under local anaesthesia with 2% Xylocaine™ and with intravenous sedation with propofol as needed. The operative procedure was accomplished within 30 min, and the drainage tube was left in place for 3–5 days. CT scans were performed daily from days 1 to 5. Results. In 11 of 13 cases, clots were evacuated successfully and patients regained consciousness within 2 hours. Recoveries occurred without significant sequelae. In the remaining 2 cases, the drainage tube was found to be obstructed by a blood clot such that the haematoma was unaffected. A traditional craniotomy was performed within 8–12 hours, and these 2 patients recovered consciousness within the subsequent 6 hours. Conclusion. Burr hole evacuation followed by drainage under negative pressure is a safe and effective method for emergency management of a pure traumatic epidural haematoma. To assure safety patients given this procedure should be monitored by daily CT scans. Decompressive craniotomy should be performed if consciousness does not improve within several hours.     

Avoidable factors that contribute to complications in the surgical treatment of chronic subdural haematoma

Summary The results of a personal series of 44 consecutive patients undergoing burrhole evacuation and closed system suction drainage for chronic subdural haematoma are presented. 43 patients made a complete recovery and one was left with moderate disability. Contralateral weakness in one patient, recurrence of haematoma in another, and a new contralateral haematoma in a third were the only complications.The operative procedures responsible for the rather low complication rate in this series are described. It is concluded that to avoid complications following surgical treatment of chronic subdural haematoma, attention must be paid to the following factors: evacuation of the haematoma through two burrholes overlying the subdural collection; attention to ensure free communication through the subdural space between the two burrholes; identification and opening of additional loculations overlying the cortex; irrigation of the subdural space to ensure as complete an evacuation of the subdural collection as possible and the use of closed system suction drainage, nursing the patient flat, and intravenous hydration of the patient for three days. In addition, in patients with coagulopathy, correction of these disorders before surgery is most essential.     

Burr Hole Evacuation of Chronic Subdural Haematomas Followed by Continuous Inflow and Outflow Irrigation

Summary  Chronic subdural haematomas are prone to recollect, increasing the risk of further complications and death. Burr hole evacuation followed by continuous irrigation of a Ringer solution into the remaining subdural cavity, allows remaining blood to be washed out and the brain to re-expand.  This technique was compared with burr hole evacuation either without or with a passive drainage and craniotomy, respectively.  Reformation of haematomas after continuous irrigation occurred in 2,6% (2/77); more than a twelve (32,6%; 15/46) and a nine (23,8%; 5/21) times rate reduction compared to burr hole evacuation without and with passive drainage, respectively. Compared to the craniotomy results, the rate dropped seventeen times (44,4%; 4/9).  Expect from the two rebleedings in 77 haematomas operated on through burr holes followed by irrigation, all patients recovered including nine recurrent haematomas re-operated on by this method.  Recurrent haematomas operated on through burr hole evacuation alone or with insertion of a passive drainage, recollected in 50% (2/4) and 33,3% (2/6). Similar rate after craniotomies was 11,1% (1/9).  Neither infections nor deaths followed burr hole evacuation combined with continuous irrigation, whereas 5,3% (2/38) and 5,9% (1/17) suffered from empyema after burr hole evacuation alone or combined with a passive drainage, respectively. Five (9,1%) of these 55 patients died either from empyemas (three) or rebleedings (two).  Recurrent haematomas evacuated through a craniotomy had no complications from infections.  Compared to other methods, continuous irrigation reduces the need for re-operation significantly by preventing haematoma recurrence and empyema formation. Contrary to other surgical techniques, haematoma recurrence after second time surgery did not occur.     

Postoperative intracranial haemorrhage: a review

Postoperative haemorrhage (POH) is one of the most serious complications of any cranial neurosurgical procedure and is associated with significant morbidity and mortality. The relative paucity of work investigating this postoperative complication prompted us to undertake a review of the literature, focussing on demographic, clinical, and surgical risk factors. A literature search was undertaken using Ovid MEDLINE (1950–2009) using keywords including craniectomy, craniotomy, neurosurgery, intracranial, reoperation, repeat craniotomy, postoperative, haemorrhage, haematoma, and bleeding. The rates of POH following intracranial procedures reported in the literature vary greatly, and meaningful comparison is difficult. We defined postoperative haemorrhage as that following craniotomy, which is clinically significant and requires surgical evacuation. Risk factors include pre-existing medical comorbidities including hypertension, coagulopathies and haematological abnormalities, intraoperative hypertension and blood loss, certain lesion pathologies including tumours, chronic subdural haematomas, and deficiencies in haemostasis. We conclude by providing recommendations for clinical practice based on the literature reviewed to aid clinicians in the detection and avoidance of POH.     

Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma

Summary Background. Chronic subdural haematoma is one of the most common entities encountered in daily practice. Many methods of treatment have been reported, each with its own advantages and disadvantages. Method. The authors present a novel technique for the management of chronic subdural haematoma which is a variation of a closed drainage system. After evacuation of the haematoma through a single burr hole, we inserted a Jackson Pratt drain into the subgaleal space, with suction facing the burr hole, allowing for continuous drainage of the remaining haematoma. Findings. We used the method for over 4 years to treat 224 patients. Seventeen patients (7.6%) needed a second operation for a recurrence of the haematoma no patient required a third operation. Postoperative complications developed in 3 patients. Two patients died while in the hospital, a mortality rate of 0.9%. Conclusions. The use of suction assisted evacuation, is followed by results that compare satisfactorily to reports of previous methods, with a low rate of recurrence and complications. It is relatively less invasive and can be used in high risk patients.     

Characteristics and management of ruptured distal middle cerebral artery aneurysms

Summary Objective. Distal middle cerebral artery (dMCA) aneurysms are very rare with a reported frequency of 2–6%. Typically, patients with ruptured distal MCA aneurysms have poor clinical outcomes because often there is both a subarachnoid haemorrhage (SAH) and an intracerebral haematoma (ICH). The goals of this study were to identify the characteristics of the distal MCA aneurysms and evaluate the optimal treatment for a good outcome. Methods. The clinical, neuroradiological and operative records of 8 patients with a ruptured distal MCA aneurysm who underwent surgical management were reviewed retrospectively. The outcomes were presented according to the Glasgow Outcome Scale (GOS). Results. The clinical characteristics of the patients with ruptured dMCA aneurysms included the following: (1) a fusiform appearance in five out of eight (63%) patients. (2) Mean aneurysm size of 9.4 mm (range 2–35 mm). (3) The location being M2 (insular segment) in three, M2-3 junction in three, and M3 (opercular segment) in two patients. (4) Brain CT images revealed both SAH and an ICH in six of eight (75%) patients with the mean size of the ICH being 10 cc (range 5–25 cc). (5) Re-bleeding occurred in four out of eight (50%) of patients. All patients underwent early surgical treatment and the procedures used for surgical repair were, clipping in five patients, trapping in two, and trapping with end-to-end bypass surgery in one patient. Clinical outcomes were poor in two patients (death) due to severe brain swelling. Conclusions. In this study, dMCA aneurysms had a fusiform shape and a high re-bleeding rate; if ruptured, there was generally ICH and SAH. A good clinical outcome was associated with adequate control of brain swelling and early surgery to prevent re-bleeding.     

Spontaneous intracerebral haemorrhage in adults: a literature overview

Summary Background. A large number of reports have analysed epidemiology, pathogenesis, symptomatology, diagnostics and options for medical and surgical treatment of intracerebral haemorrhage. Nevertheless, management still remains controversial. The purpose of the present review is to summarise the clinical data and derive a current updated management concept as a result. Methods. The analysis was based on a Medline search to November 2006 for the term “intracerebral haemorrhage” (ICH). The clinical query functions were optimised for aetiology, diagnosis and therapy to limit the results. A total of 103 articles were found eligible for review. Findings. Race, age and sex influence the occurrence of ICH. Moreover, hypertension and alcohol consumption are the paramount risk factors. The most frequent pathophysiological mechanism of ICH seems to be a degenerative vessel wall change and, in consequence, rupture of small penetrating arteries and arterioles of 50–200 μm in diameter. The symptomatology depends on the size of ICH, possible rebleeding and the occurrence of hydrocephalus or seizures. The outcome is worse with concomitant occurrence of intraventricular haemorrhage. Treatment with recombinant factor VIIa (rFVIIa) within four hours after the onset of ICH limits the growth of haematoma, reduces mortality and improves functional outcome. Minimally invasive surgery tends to improve functional outcome. Conclusion. A systematic knowledge of currently available data on epidemiology, pathogenesis and symptomatology, the use of diagnostics and the different conservative and surgical treatment options can lead to a balanced management strategy for patients with ICH. Correspondence: Dr. Daniel H?nggi, M.D., Department of Neurosurgery, Heinrich-Heine-University, Moorenstra?e 5, Geb. 13.71 40225-Düsseldorf, Germany.     

A new sterilization technique with balloon-tube thoracostomy for thoracic empyema

Objective: Failure or prolongation of treatment for refractory thoracic empyema by the current chesttube drainage technique is often due to sterilization difficulties. Insufficient sterilization prolongs hospitalization, and is often associated with life-threatening complications and/or additional invasive surgical procedures. A new chest-tube sterilization technique aimed at making it less invasive and shortening the therapy is proposed.Methods: Following pretreatment for complications including loculation, bronchopleural fistula, or corticated lung, a double-lumen trocar catheter was introduced at the bottom of the empyemic cavity through the lateral chest wall. Then, a Foley balloon urethra-catheter was inserted and attached just inside the anterior chest wall at the top of the cavity for the evacuation of intrathoracic air. After irrigation of the cavity with distilled water once or twice, the cavity was completely filled with a bactericidal solution which was left in place for 30–60 minutes, followed by an antibiotic solution for more than 20 hours.Results: Among the five treated post-lobectomy or pneumonectomy cases, sterilization was obtained after only one treatment in four cases and after two courses in the other. Catheterization duration from the initial treatment was 2–13 days. Neither recurrence nor treatment-related major complications were observed.Conclusions: This balloon-tube thoracostomy technique is simple, minimally invasive and cost-effective, due to shortening of the treatment time with minimal manpower and equipment requirements. It is thus a promising therapeutic approach to thoracic empyema and has the potential for application to other intrathoracic disorders.     

Thyroid surgery: postoperative hematoma—prevention and treatment

Background and aims Postoperative haematoma formation is a fortunately rare but potentially life-threatening complication of thyroid surgery. This paper aims to identify potential aetiological factors, describe surgical techniques and newer haemostatic agents that may be used to minimise the risk of haematoma formation and propose surgical strategies to deal with haematoma formation.Materials and methods An extensive literature search as well as own considerable experience in a tertiary referral centre endocrine surgical unit was drawn upon to review this topic.Conclusions Postoperative haematoma may have a multifactorial aetiology. Numerous manoeuvres and surgical haemostatic agents may be employed to minimise the risk of haematoma formation but are no substitute for meticulous haemostasis. In the event of haematoma formation, early surgical re-intervention is strongly advocated with due care given to at risk structures.Presented at the International Symposium, Modern Technologies in Thyroid Surgery”, 10–11 February 2006, Halle/Saale, Germany.     

New tube for the diagnosis and treatment of upper gastrointestinal hemorrhage

The design, use, and applications of a new tube for the treatment and diagnosis of upper gastrointestinal hemorrhage are presented. The tube incorporates suction, air sump, and irrigating components in a triple-lumen construction. The tube allows constant irrigation of the bleeding stomach with large quantities of irrigant that may contain antacids, vasoconstrictors, or both. The efficient evacuation of the stomach may result in more productive gastroscopy and upper gastrointestinal roentgenographic examinations. The tube can provide early warning of rebleeding as well as perhaps providing definitive or temporizing therapy in some cases of bleeding.     

A spontaneous retroperitoneal haemorrhage resulting in abdominal compartment syndrome requiring laparotomy: A case report and proposed management algorithm

Introduction and importanceSpontaneous Retroperitoneal Haemorrhage (SRH) is a rare condition, which in its extreme state can result in Abdominal Compartment Syndrome (ACS). The aim of this case report is to provide an overview of the diagnosis and management of SRH and to present an algorithm to inform and guide clinical decision-making in the context of ACS.Case presentationA 74-year-old woman with multiple risk factors for SRH developed a tense abdomen in ICU post-cardiac graft study. Radiological imaging confirmed multiple bleeding points to the contralateral side of the graft access site. She underwent endovascular treatment for her condition, however, developed ACS necessitating surgical evacuation of the haematoma.Clinical discussionSRH is a rare condition that may be difficult to diagnose on physical exam. Medical, endovascular and surgical approaches are recognised treatments. ACS is an extreme variant of SRH and although endovascular management can specifically address the acute bleed, surgical evacuation of the haematoma is the only treatment that can effectively reduce abdominal compartment pressures.ConclusionSRH can cause abdominal compartment syndrome with subsequent multiorgan failure. Ultimately, as outlined in this case, surgical evacuation of the haematoma was the only treatment able to reduce abdominal compartment pressures.     

Strict Closed-System Drainage for Treating Chronic Subdural Haematoma

Summary. A comparative study chiefly of the recurrence rate of chronic subdural haematoma after two treatment modalities was conducted. Patients were divided into a burr hole strict closed-system drainage group (SCD group; n=56) and a burr hole closed-system drainage with irrigation group (CDI group; n=45). The burr hole strict closed-system drainage involved simply inserting a drainage tube into the haematoma cavity as quickly as possible after minimally incising the haematoma capsule. The introduction of air into the haematoma cavity was prevented, and irrigation was not performed. Symptoms in both groups disappeared soon after surgery, with no postoperative complications. Haematoma recurred in one patient (1.8%) of the SCD group compared with 5 (11.1%) of the CDI group. The rate of recurrence was significantly lower for the SCD than for the CDI group (p<0.05). In 4 of 5 recurrences in the CDI group, the volume of residual intracapsular air was sufficient after initial surgery. These results suggested that postoperative residual intracapsular air is a factor contributing to recurrence. Burr hole strict closed-system drainage is a simple, less invasive procedure with which to treat chronic subdural haematoma and the outcome is excellent. Furthermore, prevention of intracapsular air intrusion during surgery might help prevent recurrence.     

Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases

Summary Background. The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre. Method. Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2). Findings. The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diplo? (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 ± 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4–5) and 8 (26.7%) had poor results (GOS 1–3). Conclusions. Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.     

A rare case of digestive tract hemorrhage of extraluminal origin after total gastrectomy

The authors report on a case of digestive bleeding (melaena and enterorrhagia) in a patient undergoing total gastrectomy for gastric cancer and later splenectomy for subcapsular haematoma in a different hospital. The source of bleeding was not intraluminal; the bleeding arose from double erosion of the gastroduodenal artery in the tract above the anterior surface of the pancreas, close to the dehiscent duodenal stump. The blood flowed mainly into the enteric district through the open stump thus causing the clinical signs described. The diagnosis was made during an emergency surgical operation for haemorrhagic shock. The patient underwent haemostasis with two stitches on the gastroduodenal artery, external drainage of the duodenum with a Petzer tube, laparostomy of the infected area and ileostomy. After three months he had completely recovered.     

Outcome of cerebral amyloid angiopathic brain haemorrhage

Background  Abnormal amyloid protein can be deposited in the wall of cerebral arteries leading to fragility and intracerebral haematoma in patients with cerebral amyloid angiopathy. Diagnosis can be done only histologically. The indication of surgically treating intracerebral haemorrhage caused by amyloid angiopathy is controversial. There are studies showing a high mortality and a high rate of recurrent bleeding. Others show almost no recurrent bleeding and a very low mortality and a third party states that even when recurrent intracerebral haemorrhage occurs, re-evacuation should be performed. In the present retrospective study a population of 99 patients suffering from cerebral amyloid angiopathy-related cerebral haemorrhage has been studied, to investigate the surgical outcome. Method  Ninety-nine patients were histologically diagnosed with cerebral amyloid angiopathy in our department from 1991–2004. The outcome has been established by the Glascow Outcome Score. Findings  It could be shown that intraventricular bleeding and age >75 years increased the mortality after operative evacuation. Recurrent bleeding occurred in 22% of patients. After re-evacuation at least half of the patients survived leading to the suggestion to re-operate a recurrent bleeding since patients have a chance to survive even when the Glascow Outcome Score is 3. The overall mortality in the observed population was 16% and 11% had a very good neurological recovery based on a Glascow Outcome Score of 4–5. The operative outcome in amyloid angiopathy related intracerebral haemorrhage is similar to this of intracerebral haemorrhage induced by other causes like hypertensive bleeding. Conclusions  Possible cerebral amyloid angiopathy is no contraindication for evacuation of brain-haematoma, and especially not in patients younger than 75 years old without an intraventricular haemorrhage.     

Spontaneous intracerebral haemorrhage: a surgical dilemma

The optimal management, surgical or otherwise, of a patient following a spontaneous intracerebral haemorrhage (ICH) remains controversial. A survey of British neurosurgeons was carried out to assess current attitudes and practice. Patient management was most consistently influenced by the depth (71% agreement), dominance (74.3% agreement) and site (44.7%) of the haematoma. Almost half of neurosurgeons said they would evacuate an ICH in a deteriorating patient, but management choice was very varied in stable patients. However, 80% of the same respondents felt evacuation was helpful in reducing mortality, and 71.3% morbidity. Fifteen per cent of respondents were not influenced by the size of an ICH, but 31% would readily operate on haematomas with volumes of between 50 and 80 ml. Over 30% felt that there was no optimal time for surgical evacuation, but 66.9% felt delayed evacuation was helpful. Premorbid dependency was a stronger influence than age on management choice. Despite these variations, over half felt that they were consistent in their treatment of ICH. However, 81% expressed surgical uncertainty. Furthermore, respondents demonstrated a significant tendency to intervene surgically more readily in ICH related to aneurysm or AVM. Results from a prospective randomized controlled trial to assess the role of surgery are urgently needed.     

Capsule plication as a protective measure against post-operative intracapsular haematoma formation following trans-sphenoidal removal of pituitary macroadenoma

Summary   Background. Post-operative haematoma and visual deterioration are rare but serious complications after trans-sphenoidal surgery. For more reliable decompression of the optic nerve, we introduce a new technique for volume reduction of the cavity remaining after trans-sphenoidal resection of macroadenomas. Technique. After intracapsular removal of the adenoma, the suprasellar portion of the tumour ‘capsule’ spontaneously prolapsed into the sella turcica. The lowest part of the prolapsed capsule was sutured and/or clipped to reduce the volume of the residual cavity remaining after tumour resection. Findings. A total of 23 patients with macroadenomas extending to suprasellar area had visual symptoms and were treated by trans-sphenoidal surgery. In seven (30%) patients, computerised tomography scans on the first post-operative day demonstrated haematoma formation in the residual cavity. The magnetic resonance imagings on the seventh post-operative day, however, showed approximately 80% reduction in the tumour size. Visual disturbance improved in 20 patients (87%). No patient had post-operative deterioration of visual function. The complications in this series included transient diabetes insipidus in three patients and panhypopituitarism in one patient. Conclusions. Capsule plication is a useful measure for volume reduction of the large residual cavity after trans-sphenoidal surgery for macroadenoma. It may prevent an acute post-operative complication due to intracapsular haematoma, and improve surgical outcome in well selected cases. Correspondence: Masahiko Kitano, M.D., Department of Neurosurgery, Kinki University School of Medicine, 377-2, Ohono-Higashi, Osaka-Sayama, Osaka 589-8511, Japan.     

Haematoma evacuation does not improve outcome in spontaneous supratentorial intracerebral haemorrhage: A case-control study

Summary Surgical intervention in supratentorial intracerebral haemorrhage (ICH) is still controversial. We assessed the value of haematoma evacuation with a case-control study. 145 consecutive patients with supratentorial spontaneous ICH without tumour or vascular abnormalities were analysed. Haematoma evacuation was performed in 24 patients. Age, sex, Glasgow Coma Scale (GCS), level of consciousness, pupillary reaction on admission, localisation, aetiology and volume of the haematoma, presence of ventricular blood, and Glasgow Outcome Scale (GOS) on discharge were analysed. From statistical analysis 40 patients >80 years and with haematoma volume <10ml, who were always treated conservatively, were excluded. Prognostic factors retained from a multiple regression model with the dichotomised GOS scale (GOS 1–3, 4+5) as response variable were GCS, haematoma volume and location. The only difference between all medically treated and operated patients was haematoma volume, which was larger in the operated patients. All 24 evacuated cases could be matched to a medically treated control regarding age, haematoma volume and location, GCS, and pupillary reaction. Significant differences between the two groups could not be detected. Outcome was not different between the two groups. After separating the sample into patients with and without ventricular haemorrhage, there was no different outcome between the two groups either. We conclude that haematoma evacuation did not improve outcome in supratentorial spontaneous ICH. Since haematomas were evacuated mainly in clinically deteriorating patients, our data suggest that the only effect of haematoma evacuation is to stop progressive deterioration rather than to improve overall clinical outcome.     

Surgical experience with massive lobar haemorrhage caused by cerebral amyloid angiopathy

Summary Nineteen patients with massive lobar haemorrhage without angiographic lesions received direct or stereotactic surgery, and biopsy specimens were examined histologically. Ten patients (53%) were found to have vessels positive for Congo-red staining, and demonstrating amyloid angiopathy. In the patients with amyloid angiopathy, CT scan and surgical findings were investigated. Subarachnoid haemorrhage (9/10), irregularly shaped haematoma (9/10) and fluid-blood density level in the haematoma cavity (7/10) were frequently found on CT scan. The characteristic surgical findings in patients treated by direct surgery were subarachnoid haemorrhage adjacent to intracerebral haematoma (8/8) and the existence of a tangle of vessels in the haematoma cavity (4/8). Evacuation of haematomas was relatively easy, and difficulty of haemostasis was not encountered during surgery.     

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 surgical interventions for ruptured cerebral aneurysms. Intra-operative premature rupture is defined as a rupture which occurs before the securing of the parent arteries or the neck of the aneurysm and is out of control, at least temporarily. The causes and management were retrospectively analyzed by reviewing 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 arachnoid opening (8.3%), 2.) haematoma removal (12.5%), 3.) brain retraction (16.7%), 4.) aneurysm dissection (62.5%). A double suction technique was used to control bleeding and haemostasis with a small piece of cotton or a temporary 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 swelling and partial resection of the brain had to be done to secure temporary clipping. The double suction technique and primary haemostasis using a small piece of cotton or temporary clip resulted in good outcome even in cases with premature rupture. However, very early premature rupture also occurred although its incidence was extremely rare. The removal of part of the brain can secure the working space but the outcome was poor.