Acute Neurological Emergency With Varied Challenges: An Unusual Occurrence and Multimodal Team Approach

Subarachnoid hemorrhage (SAH) is a devastating condition associated with high mortality and morbidity. Vascular malformations are the most common cause of non-traumatic SAH in patients less than 40 years old. We present a case of a 37-year-old male who presented on the second day of ictus with left-sided hemiparesis and a low Glasgow Coma Scale score (E1VTM5). Non-contrast computed tomography (NCCT) scan of the head was suggestive of right basi-frontal hematoma, SAH, and hydrocephalus (HCP). Given SAH with HCP, the neurosurgical team initially placed a left frontal Ommaya. Cerebral digital subtraction angiography suggested an arteriovenous malformation (AVM) and two anterior cerebral artery aneurysms. Endovascular coiling of the ruptured A2-A3 junction aneurysm was done initially, followed by decompressive craniectomy and evacuation of hematoma and clipping of the still leaky A2-A3 junction aneurysm, also on the same day. The patient recovered in the intensive care unit and was discharged home in good health on the 18th postoperative day. Our case report presents the unique challenge of neuroprotection and maintaining intra-cerebral dynamics in a patient with cerebral aneurysms, AVM, SAH, and hematoma between coagulation (to prevent intra-cerebral hemorrhage) versus anti-coagulation (to prevent emboli during coiling), hypertensive therapy (to prevent cerebral vasospasm) versus relative normotension (to prevent rebleed), and early intervention (surgery and coiling) versus staged procedure. Our multimodal team approach was highly effective in successfully managing the patient and thus highlights its role in managing such critically ill patients.