Perioperative Stroke in MCA Aneurysm Surgery: The Hidden Risks of Amphetamine Use

Abstract

Background/Objectives: Perioperative strokes are a rare but recognized complication of cerebral aneurysm surgeries, often influenced by patient-specific factors. Amphetamine abuse, known for its vasospastic effects, is an underexplored risk factor in the neurosurgical setting. This report highlights the clinical and perioperative challenges associated with acute undisclosed amphetamine abuse in a patient undergoing elective clipping of an unruptured middle cerebral artery (MCA) aneurysm. Methods: A 46-year-old male presented with a 3 mm broad-based unruptured aneurysm in the proximal M1 segment of the right MCA. The patient reported a history of illicit drug use, including intravenous consumption. Upon further questioning, he admitted to intermittent use of amphetamines, although he denied any recent use. Elective aneurysm clipping via a transsylvian approach was performed after multidisciplinary consensus. Postoperatively, the patient developed anisocoria, prompting an emergency CT with perfusion and angiography, showing significant findings. Further imaging revealed a bilateral superior cerebellar artery territory infarction. Given the patient's medical history, a toxicology screening later confirmed recent amphetamine use. Conclusions: This case highlights the need for preoperative evaluation, including routine toxicology screening, in patients with a history of substance abuse. Amphetamine use may present perioperative challenges and increase the risk of complications like vasospasm and stroke.

Keywords: amphetamine; middle cerebral artery aneurysm; neurosurgery; perioperative stroke; substance abuse; vasospasm.

Figure 1

Presents a detailed depiction of the 3 mm aneurysm. Panel 1 illustrates a laterolateral projection, with (1a) viewed from the right and (1b) from the left. Panel 2 shows an anteroposterior projection, with (2a) from the posterior and (2b) from the anterior aspect.

Figure 2

Representative images illustrating the diagnostic and surgical management of the proximal MCA aneurysm (A) Preoperative digital subtraction angiography (DSA) showing the unruptured proximal MCA aneurysm. (B) Intraoperative view of the exposed proximal MCA aneurysm before clipping. (C) Application of the aneurysm clip during the surgical procedure. (D) Postoperative DSA confirming complete exclusion of the aneurysm with preserved blood flow in adjacent vessels.

Figure 3

Non-contrast CT and MRI of the brain showing a hypodense area in the superior cerebellum, consistent with an infarction in the territory of the superior cerebellar artery (SCA). This finding correlates with the patient’s perioperative neurological symptoms. Panels (1a–c) show the postoperative CT scan in sagittal, coronal, and axial views. Panel (2a) displays the postoperative brain MRI in T2-FLAIR sequences, while panel (2b) presents diffusion-weighted imaging with apparent diffusion coefficient mapping sequences and (2c) present standard diffusion-weighted imaging sequences.