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

Area of Science:

• Neurosurgery
• Neurology
• Vascular Neurology

Background:

• Delayed symptomatic vasospasm is a rare complication following surgical clipping of unruptured intracranial saccular aneurysms.
• Few cases report vasospasm occurring more than two weeks post-intervention.
• This case is the first to document refractory vasospasm despite aggressive first-line therapy.

Observation:

• A 67-year-old female presented with delayed vasospasm (post-op day 29) affecting the right middle cerebral artery (MCA) M2 segment after surgical clipping.
• Initial treatment with intra-arterial verapamil, volume expansion, permissive hypertension, and nimodipine was followed by recurrent vasospasm.
• Magnetic resonance imaging (MRI) revealed infarction in the right basal ganglia, frontal, and parietal lobes, complicated by super-refractory status epilepticus.

Findings:

• The patient experienced significant neurological deficits including left hemiparesis, dysarthria, headache, vomiting, left lower extremity weakness, left visual field defect, and left-sided neglect.
• The vasospasm was refractory to initial aggressive management, indicating a severe and complex clinical course.
• The case underscores the unpredictable nature and potential severity of delayed cerebral vasospasm.

Implications:

• Cerebral vasospasms following aneurysm clipping are rare and often not monitored post-recovery.
• Current hypotheses for delayed/refractory vasospasm involve blood breakdown products, mechanical responses, or trigemino-cerebrovascular system (TCVS) reactions.
• Extended monitoring of patients for up to a month post-surgical clipping is warranted due to the unpredictable timing and refractory nature of these events.