A comparative investigation of the pathogenetic factor in symptomatic cerebral vasospasm was made by quantitative histological and clinical studies in four patients who died immediately of sympto matic cerebral vasospasm (Cases 1-4) and in two who died without fatal cerebral vasospasm (Cases 5 and 6). Histological examination of the brain from Cases 1 and 2 found many white and fibrin microthrombi together with ischemic and infarctic changes in the territories of spastic arteries, which corresponded to the low-density areas (LDAs) observed on computed tomographic (CT) scans and the typical neurological symptoms. In Case 3, who had suffered severe vasospasms in bilateral ante rior cerebral and middle cerebral arteries, bilateral LDAs were observed on CT scans and multiple fibrin thrombi were seen diffusely throughout the brain. In Case 4, extensive bilateral LDAs (It > rt) were observed on CT scans, and multiple microthrombi were seen diffusely but predominantly in the left cerebral hemisphere. Only in Case 3 the possible complication of disseminated intravascular coagulation could not be ruled out. Only negligible thrombi were observed in Cases 5 and 6, whose immediate cause of death was considered to be acute hydrocephalus and aneurysmal rerupture, re spectively. Distributions of microthrombi were significantly greater in the regions clinically identified to have been ischemic or infarctic.

A series of 55 patients with ruptured cerebral aneurysms were treated with moderate removal of subarachnoid clot followed by intracranial irrigation with pH 8.0 Hartmann solution containing 1 mg/ml of methylpredonisolone sodium succinate after the aneurysmal clipping during early (before day 3) operation. Six (11%) of the 55 patients suffered vasospasm syndrome postoperatively. The clinical results are significantly better than a series of 68 patients operated on and treated before day 3 by intracranial irrigation with Hartmann solution (pH 8.0) only. The possible preventive effect of direct intracranial administration of steroid hormone is discussed.

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