Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention. 1. Introduction The incidence of unruptured aneurysms is progressively increasing worldwide [1, 2]. IAR remains a dreaded complication, with significant morbidity and mortality in affected patients [3]. Great strides have been made in the management of aneurysmal subarachnoid hemorrhage (SAH); however, outcomes have still not improved significantly [4]. This may be attributed to mechanisms such as early brain injury and delayed neurological ischemia, both of which can occur even with successful aneurysm clipping. The underlying pathophysiological mechanisms are not fully understood, and research is ongoing in this area [5, 6]. There is increased vulnerability to aneurysm rupture during the intraoperative period, and various challenges must be dealt with by perioperative physicians, including surgeons, neurointerventionalists, neuroanesthesiologists, and neurophysiologists. However, there is little data to guide the perioperative management of IAR, although intraoperative course may be the most important factor in determining overall neurological outcome. Furthermore, the literature mainly focuses on the management of aneurysm and SAH in toto. In this paper, we address the issues and controversies related to the management of IAR. Special reference is given to future directions in the management of such cases. 2. Methods We performed a Pub Med, Scopus, Web Science, and Google search [1 January 1981 to 31 December 2012] using search terms including “Cerebral aneurysm,” “Intracranial aneurysm,” “Management,” “Anesthesia,” and
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