Surgical repair of intracranial aneurysm was introduced approximately 70 years ago (1). Hallmarks of improvement for treatment of patients with cerebral aneurysms have been the implementation of the operating microscope in the 1960s and the application of calcium antagonists in the late 1980s, which served to prevent hemorrhage-associated cerebral vasospasm and reduce cerebral ischemia. Endovascular treatment options for cerebral aneurysms were developed in the 1970s, but it was not until the early 1990s when the gold standard of surgical repair was challenged by the introduction of functional embolic material in the form of Guglielmi detachable coils (2).

Recently, a large multicenter study (International Subarachnoid Aneurysm Trial, n=2143) determined that endovascular coiling resulted in an improved outcome after one year, compared to conventional microsurgical aneurysmal repair (3). Even though the long-term outcome measures are still to be collected, it is likely that some centers will favor endovascular intervention whenever possible (4,5). It is conceivable that expertise with the conventional surgical approach will diminish for both neurosurgeons and anesthesiologists as the number of cases that require open aneurysmal repair diminish. This review summarizes intraoperative management of patients after aneurysmal subarachnoidal hemorrhage (aSAH). Other aspects, including epidemiology of aSAH, clinical grading, and pathophysiology, major medical problems, timing of surgery, pre-and postoperative intensive care management, and diagnosis and treatment of vasospasm, are discussed in detail elsewhere in this book.

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