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

Abstract

Delayed ischemic stroke associated with intractable vasospasm after clipping of unruptured intracranial aneurysms (UIAs) has been rarely reported. We report a patient with delayed ischemic stroke associated with intractable vasospasm following UIA clipping. A middle-aged female underwent surgery for unruptured middle cerebral artery bifurcation aneurysms. The patient tolerated the neurosurgical procedure well. Seven days postoperatively, the headache was unbearable; a postcraniotomy headache persisted and abruptly presented with global aphasia and right-sided hemiplegia after a nap. Emergency digital subtraction angiography showed severe luminal narrowing with segmental vasoconstriction, consistent with severe vasospasm. The patient's neurological deficit improved after chemical angioplasty. Neurosurgeons should pay close attention to this treatable/preventive entity after neurological deterioration following UIA clipping, even in patients without subarachnoid hemorrhage.

Keywords: Aneurysm; Angioplasty; Headache; Ischemic stroke.

Fig. 1.

Digital subtraction angiography (DSA) findings and transcranial Doppler changes before and after treatment. (A) DSA image showing a normal vascular diameter and normal vascular appearance at the initial exam. Contrast stagnation was observed at the left middle cerebral artery (MCA) bifurcation, suggesting an unruptured saccular aneurysm (white arrow). (B) Severe luminal narrowing around the MCA bifurcation (white arrowheads) and overdilated M2–3 segments were observed on DSA at the first neurologic deterioration. (C) Marked resolution of vasospasm was shown after intraarterial nimodipine. (D) Diffusion restriction at the left MCA territory was confirmed at the transferred hospital. (E) The mean flow velocity was increased (156 cm/s, 55 mm) and the Lindegaard ratio was 5, which are indicative of moderate to severe vasospasm. (F) Improvement of vasospasm was shown by transcranial Doppler monitoring after 2 nimodipine injections.

Fig. 2.

Initial neuroimages of the patient at the ischemic symptom onset. (A) Computed tomography scan demonstrates the successful clipping of the left middle cerebral artery (MCA) bifurcation aneurysm without significant hyperacute stroke. Very bright, high signal intensity at the left Sylvian fissure regarding the metal clip artifact was observed (white arrow). (B) Some suspicious hyperintense vessel signs on the fluid attenuated inversion recovery image suggested that ischemic changes (white arrowheads) are noted in the left Sylvian region and temporal lobe. (C) Magnetic resonance perfusion showing marked increased mean transit time in the left MCA distribution.