Subarachnoid hemorrhage during aneurysm coiling

Intraprocedural rupture of an intracranial aneurysm is a potentially catastrophic complication, but can be even more devastating in a heparinized patient in an offsite interventional suite. Understanding how to respond to such an event is essential to good patient outcome. Case description A 67-year old woman with hypertension presented to the emergency department with the sudden onset of the worst headache of her life. Upon initial neurologic examination, she was drowsy but arousable, and was disoriented to place. The remainder of her examination was intact. A noncontrast head computed tomography scan was obtained, which showed expected diffuse subarachnoid hemorrhage (SAH) and a small hypo-attenuating spherical abnormality in the basilar artery tip. Small temporal horns were visible (an early sign of hydrocephalus) and the remainder of her ventricular system appeared slightly enlarged. After the scan's completion, the patient appeared increasingly lethargic, so a right frontal external ventricular drain was placed and set to drain at 20 cm above the tragus. The opening intracranial (ICP) pressure was 25 mm Hg. Given the patient's presentation of a Hunt-Hess grade 3 SAH, a diagnostic cerebral angiogram was obtained, with the potential to perform endovascular coil embolization should an aneurysm be discovered. The patient was brought to the interventional neuroradiology suite, where an arterial line and further intravenous access was obtained and general anesthesia was induced. Neurophysiologic monitoring was performed throughout the case. An angiogram showed a 7 mm, wide-domed, small-necked saccular aneurysm at the basilar tip.

Duke Scholars

Author Khoi Duc Than Neurosurgery