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The result of surgical treatment in cases classified as Hunt and Kosnik Grade IV and V was analysed and the surgical indication for these cases was discussed in this paper. The clinical material for this study consisted of 58 cases of Grade IV and 12 cases of Grade V. Locations of the ruptured cerebral aneurysms were as follow: Grade IV, 24 in the internal carotid artery, 12 in the middle cerebral artery, 12 in the anterior communicating artery, four in the anterior cerebral artery, and six in the vertebro-basilar artery. For Grade V there were six in the internal carotid artery, five in the middle cerebral artery, and one in the anterior communicating artery. The operation was performed within 72hours after the bleeding in 41 cases, between four and 14 days in five cases, over 15 days in 12 cases in Grade IV, and within 24hours in all 12 cases of Grade V. Overall mortality and morbidity were eight cases(31%) and 19 cases(33%) in Grade IV, and 10 cases(83%) and two cases(17%) in Grade V. Good clinical outcome was noted in 21 cases(36%) of Grade IV but was not found in any cases of Grade V. In cases of Grade IV, the rate of clinically good outcome was significantly higher in cases operated on within 72hours after bleeding(19 out of 41 cases:46%) than in cases operated on more than four days after bleeding (2 out of 17 cases:12%). Clinical outcome was not significantly influenced by the location of the ruptured cerebral aneurysm, patient's age at time of operation, use of temporary clip, presence of intraoperative bleeding from the aneurysm, CT findings, use of continuous cisternal drainage or external decompression. Causes of poor clinical outcome were primary brain damage in 23 cases(62%), vasospasm in 12 cases(32%) and other causes in two cases(6%) out of 37 poor cases of Grade IV, and primary brain damage in nine cases(75%) and primary brain damage plus vasospasm in three cases(25%) out of 12 cases of Grade V. From these results, we can conclude that surgery should be carried out within 72hours after bleeding in cases of Grade IV, irrespective of the location of the ruptured aneurysm, patient's age

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Surgical Indication Based on Operative Results for Cases Classified into Grade IV and V of Hunt and Kosnik's Classification with Ruptured Cerebral Aneurysms