Unruptured aneurysmal clipping complicated by delayed and refractory vasospasm: case report

Abstract

Background Delayed symptomatic vasospasm is a rare complication following clipping of an unruptured intracranial saccular aneurysm. There have been ten reported cases of delayed symptomatic vasospasm and only two of these occurred after 2 weeks from initial intervention. Our case is the first to document the refractory nature of such vasospasm despite aggressive first line therapy. Case presentation Here, we present a 67-year-old female who had surgical clipping of a 10x7mm right middle cerebral artery (MCA) bifurcation aneurysm. Her surgery and initial postoperative course were uncomplicated, but she presented with acute left hemiparesis, dysarthria, headache and vomiting on post-op day 29 secondary to vasospasm of M2. She was initially stabilized with intra-arterial verapamil then managed with volume expansion, permissive hypertension, and nimodipine. She developed recurrent vasospasm of M2 the following day and was again treated with intra-arterial verapamil. Magnetic resonance imaging (MRI) brain showed an infarction involving the right basal ganglia, frontal lobe, and parietal lobe and her hospital course was complicated by super-refractory status epilepticus. At her follow up appointment she displayed continued left lower extremity weakness, left visual field defect, and left-sided neglect. Conclusions Overall, cerebral vasospasms associated with unruptured aneurysms remain rare complications and are not often monitored for after initial recovery. Reviewing the documented cases highlights the unpredictability of when these events occur with our current knowledge. Current hypotheses for the mechanisms responsible for delayed and refractory vasospasms include: blood-derived breakdown products, mechanically induced vasospastic responses, and delayed reactions from the trigemino-cerebrovascular system (TCVS). The uncertainly of these events warrants further research and supports a strong argument for monitoring patients with initial surgical clipping up to a month out from their initial procedure.

A Case of Severe Delayed Vasospasm after Clipping Surgery for an Unruptured Intracranial Aneurysm

“…Cerebral vasospasm, which is relatively uncommon, has been reported to occur after the clipping of a UIA. [7][8][9][10][11][12][13][14][15][16][17][18][19][20] Here, we reported a case of a middle-aged female who suffered from an ischemic stroke due to severe vasospasm following successful treatment of an unruptured MCA bifurcation aneurysm. The pathomechanism of the unexpected severe vasospasm remains unclear.…”

“…Nevertheless, ischemic events following unpredictable delayed vasospasm after clipping have been reported in UIA patients. [7][8][9][10][11][12][13][14][15][16][17][18][19][20] Here, we report a case in which delayed vasospasm and ischemic stroke accompanied by intractable headache occurred 1 week after the successful clipping of an unruptured MCA bifurcation aneurysm.…”

An unusual presentation of hypopituitarism caused by a sellar aneurysm

“…Currently, there are several options for treating unruptured intracranial aneurysms, including surgical clipping and different endovascular procedures. Still, minimally invasive endovascular coiling is frequently used and is considered the treatment of choice ( 19 , 20 ). Combined endovascular treatment with stent-assisted coil embolization of the aneurysm was performed successfully in our patient.…”

Arterial Supply of the Basal Ganglia: A Fiber Dissection Study

“…bPeterson et al 42 reported the results of 4 ICA, 4 MCA, and 1 PCA aneurysms in a literature review involving vasospasms that develop after clipping intracranial aneurysms. The results showed that aphasia and hemiparesis can develop from vasospasm in the ICA and MCA territories.…”

“…ACA, anterior cerebral artery; ACoA, anterior choroidal arteries; ICA, internal cerebral artery; Lla, lateral lenticulostriate artery; MCA, middle cerebral artery; Mla, medial lenticulostriate artery; PCA, posterior cerebral artery.aElkordy et al 41 reported that among 13 patients who underwent ACoA endovascular embolization to treat AVM, 1 developed transient hemiparesis-dysarthria and 1 developed hemiparesis–hemianopsia, after 4 had developed ischemia. These clinical symptoms could have resulted from ACoA injury affecting the globus pallidus.bPeterson et al 42 reported the results of 4 ICA, 4 MCA, and 1 PCA aneurysms in a literature review involving vasospasms that develop after clipping intracranial aneurysms. The results showed that aphasia and hemiparesis can develop from vasospasm in the ICA and MCA territories.…”