The High Stakes of Brain Surgery: Ruptured Brain Aneurysms
By: Brian Hoeflinger, MD
August 19, 2025 | #58
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Disclaimer: Opinions are my own. Not medical advice.
Medical Trivia of the Week
What percentage of patients with a ruptured brain aneurysm die within the first 24 hours? (the correct answer is at the end of this email)
- A) About 20%
- B) About 25%
- C) About 30%
- D) About 35%
Racing to Stop the Bleeding of a Ruptured Brain Aneurysm
Did you know that one of the most deadly and stressful situations a neurosurgeon faces is a ruptured brain aneurysm? If you don’t stop the bleeding, the patient will die.
Here’s the scenario: you are working under the light of an operating microscope, deep in the brain of a middle-aged woman. It has been hours of standing in the operating room, tediously dissecting your way along vital blood vessels toward your target, a brain aneurysm. As you re-adjust the retractor blade one final time against the swollen brain, you suddenly see the wound rapidly filling with bright red blood under high pressure, now pouring out over the edges of the brain surface.
You immediately tell the anesthesiologist that the aneurysm has ruptured and to have blood available in the room. Your first instinct is to panic as you realize the patient is now bleeding uncontrollably. Your mind quickly takes you to that place of uncertainty: “What if I can’t stop the bleeding and the patient dies?”
The atmosphere of the operating room changes instantly. The tension in the air is palpable. The patient is in peril, and you alone must finish this surgery. There is no one to take over, and the stakes are now literally life or death. And you can never forget that the patient’s family is in the waiting room counting on you.
This is a scenario that I and other neurosurgeons have faced more times than we would like. But it’s part of being a neurosurgeon.
You are faced with a crisis that you alone must resolve, and the stakes could not be higher. The well-being, and even the survival, of the patient is on the line. This is when you must fall back on your training and many years of experience.
Here is the sequence of events I follow to complete such a surgery:
What I did ahead of time, which you didn’t know, was practice placing a temporary clip on the main artery feeding the aneurysm during my initial dissection. I do this so that in the case of an unexpected rupture, I can temporarily shut off the blood supply to the aneurysm and stop the bleeding.
In this woman’s case, once the aneurysm ruptured, my assistant and I used our hand-held suction devices to keep up with the bleeding and clear the wound. I held the suction in my left hand and used an instrument in my right hand to quickly identify and define the feeding artery I had prepared earlier. I then placed the temporary clip across it. The bleeding stopped immediately.
From there, I dissected around the aneurysm itself, identifying all the blood vessels associated with it. Under the microscope, I carefully placed a permanent clip across the neck of the aneurysm to seal it off from its blood supply. I then rechecked all the surrounding vessels to make sure I hadn’t trapped one of them in the aneurysm clip. If I had, the patient would have suffered a stroke.
Finally, I took a deep breath, steadied my hand, and slowly removed the temporary clip. There was no further bleeding. A giant sigh of relief followed. But even then, near exhaustion, the surgery was not over. I still had an hour or two to close the head back up.
During these most difficult and tension-filled situations, the operating room is dead silent. As the surgeon, you are at your maximum focus. A ruptured aneurysm is one of the most deadly and stressful situations a neurosurgeon will ever face.
Impactful Quote of the Week
"Courage is not the absence of fear, but the triumph over it."
- Nelson Mandela
All my best,
Brian Hoeflinger
P.S. - if you enjoyed this newsletter, you may enjoy my book that details my life as neurosurgeon and the loss of my oldest son, Brian (see below a synopsis).
Check out My Book
Life and Death . . . Two words with such opposite meaning and which inflict such contradictory emotions and yet are so closely intertwined in our lives. As parents, we bring meaning and life into this world through our children. Our lives become defined as a result. We learn the joy, hardship, and responsibility of shaping an innocent life. But a day will come when that life will be taken. For some, death will come too soon. This is the story of my son, Brian Nicholas Hoeflinger, who died unexpectedly at age 18.
https://doctorhoeflinger.com/products/the-night-he-died-the-harsh-reality-of-teenage-drinking
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Medical Trivia Answer:
The correct answer is B) About 25%
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