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The optimal timing of surgery for patients with subarachnoid hemorrhage (SAH) has been debated over the last few decades. Recent literature largely advocates “early surgery,” namely within 48 hours after the onset of bleeding, for ruptured cerebral aneurysms. However, early surgery is not always safe for some complicated aneurysms. It can be even hazardous due to the vulnerability of the brain during the acute stage of SAH. Although elective surgery may be a useful option for better surgical outcome for these high-risk aneurysms, the actual risk of postponing surgery in the modern neurosurgical environment has not been well understood. We retrospectively analyzed the surgical outcome of our patients with SAH between January 2008 and September 2012. Our management policy for SAH is to perform clipping within 48 hours after hospitalization. Among a total of 235 patients with SAH, however, we found 43 patients who were treated after 48 hours from admission for various reasons. We analyzed the characteristics of these aneurysms, reasons for waiting, complications due to awaiting surgery, and outcomes. Among these 43 patients, the mean waiting period was 11 days (2–69 days, median; 6 days). During this period, we had four cases (9.3%) of rebleeding and three of these four patients died due to rerupture. Other complications included severe pneumonia in three (7.0%), symptomatic vasospasm and hydrocephalus in two (4.7%), respectively. These complications were all successfully treated. The reasons for elective surgery included a tight operating room schedule (23.3%), severe systemic conditions of patients (14.0%), the necessity of high flow bypass (18.6%), the time required for arranging endovascular surgery (14.0%), and elective clipping for aneurysms located in the posterior circulation (4.7%). Symptomatic vasospasm before surgery was observed in two cases (4.7%). Good outcome (GR and MD on Glasgow Outcome Scale) was achieved in 65.2% of patients treated during 3–7 day and in 60.0% of patients treated after seven days or later. The mortality was 11.6%, including three patients with rebleeding. Although “early surgery” is critical to treat patients with aneurysmal SAH, it is also true that

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Risks Related to Elective Surgery for Ruptured Cerebral Aneurysms: Reassessment of Risks of Preoperative Patient Management in Modern Neurosurgical Era