Introduction: Aneurysmal subarachnoid hemorrhage is a life-threatening condition associated with poor clinical and neurological outcomes. Advances in surgical and endovascular interventions have improved mortality rates in patients with ruptured intracranial aneurysm. Objective: To evaluate the impact of early microsurgical management on clinical outcome of patients with ruptured intracranial aneurysm. Method: Retrospective observational study with patients admitted at the Emergency Department of a public tertiary center with aneurysmal subarachnoid hemorrhage, from October 2015 to June 2020. Results: Two hundred twenty-eight patients were treated with microsurgical techniques, totalizing 289 clipped aneurysms. One hundred sixty-nine (74.12%) patients were women and 59 (25.88%) men. At admission, 166 (72.81%) patients were classified according the Hunt-Hess Scale as I to III and 62 (27.19%) were IV and V. One hundred twenty-six (55.26%) were treated <48h following subarachnoid hemorrhage and 102 (44.74%) >48h. After six months of follow-up, 89 (70.63%) early treated patients (<48h) were mRS≤3, 16 (12.70%) were mRS 4 or 5 and 21 (16.67%) died, with an average hospital stay of 28 days; while 49 (48.04%) late treated patients (>48h) were mRS≤3, 19 (18.63%) were mRS 4 or 5 and 34 (33.33%) died, with an average hospital stay of 49 days. Conclusion: Aneurysmal subarachnoid hemorrhage is a serious disease and early microsurgical management represents a key point to successfully treat this life threatening condition.

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Introduction Aneurysms of the vertebrobasilar junction are rare, but when present, they are often associated with fenestration of the basilar artery. Frequently, the endovascular treatment is the first choice due to the complex anatomy of the posterior fossa, which represents a challenge for the open surgical treatment alternative. Case Report A 47-year-old man was admitted to the emergency unit with headache, diplopia, neck pain and mental confusion. The neurological exam showed: score of 15 in the Glasgow coma scale (GCS), no motor or sensitivity deficit, palsy of the left sixth cranial nerve and Hunt-Hess grade III. The computed tomography (CT) scan showed subarachnoid hemorrhage (Fisher III) and hydrocephalus. The patient was submitted to ventricular-peritoneal shunt. A diagnostic angiography was performed with 3D reconstruction, which showed evidence of fenestration of the basilar artery associated with aneurysm in the right vertebrobasilar portion. An aneurysm coil embolization was performed without complications. The patient was discharged 19 days later maintaining diplopia, with paralysis of the left sixth cranial nerve, but without any other complaints or neurological symptoms. Discussion Fenestration of the basilar artery occurs due to failure of fusion of the longitudinal neural arteries in the embryonic period, and it is associated with the formation of aneurysms. The endovascular treatment is the first choice and several techniques are described, including simple coiling, balloon remodeling, stent-assisted coiling, liquid embolic agents and flow diversion devices. The three-dimensional rotational angiography (3DRA) is an extremely helpful tool when planning the best treatment course. Conclusion Fenestrated basilar artery aneurysms are rare and complex vascular diseases and their treatment improved with the advent of the 3D angiography and the development of the endovascular techniques.