Acute aneurysmal SAH complicated by vasospasm

Case contributed by Craig Hacking

Presentation

Sudden onset headache.

Patient Data

Age: 25 years
Gender: Female

Acute SAH in the basal cisterns and right sylvian fissure. No midline shift or herniation. Early ventriculomegaly.

Multiple aneurysms:

  1. Irregular right ICA aneurysm at the PComA origin protruding posteriorly, 4 x 3mm
  2. Right para-ophthalmic ICA aneurysm protruding medially, 3 x 3mm
  3. Left ICA ophthalmic origin aneurysm protruding anteromedially, 3 x 2mm
  4. Left ICA anterior choroidal origin aneurysm protruding posterolaterally, 3 x 2mm

DSA confirmed the ruptured aneurysm was the right PComA aneurysm which was unable to be treated endovascularly. The patient underwent EVD insertion and craniotomy for aneurysm treatment with clipping on day 1. 

At day 10 the patient had reducing GCS and meningism.

Status post right craniotomy and right PCOM aneurysm clipping. Removal of the right frontal EVD. Mild dilation of the temporal horns suggestive of early/developing hydrocephalus.

Moderately severe vasospasm is seen in basilar artery, bilateral VA, ACA, MCA, PCA and ICA cavernous and communicating segments. PCOM aneurysm clip is unchanged in position, no discrete evidence of aneurysm recurrence.

The vasospasm was treated successfully with serial intra-arterial verapamil and milranone. 

Case Discussion

Case example of vasospasm after acute aneurysmal SAH.

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