Symptomatic Cerebral Vasospasm after Surgical Ligation of Unruptured Aneurysms

Background Cerebral artery vasospasm accounts for the majority of delayed neurological deficits in ruptured aneurysm patients. We report two cases and review the literature* of patients who developed symptomatic vasospasm after treatment for unruptured cerebral artery aneurysms with clip ligation. Preand post-operative imaging and studies revealed absence of subarachnoid or focal hemorrhage. Case Description In a series of 104 consecutive cerebral artery aneurysm patients that underwent uncomplicated ligation without intra-operative rupture, two patients developed delayed neurologic deficits due to severe cerebral vasospasm. Both patients had no stigmata of rupture and were treated electively. Post-operative transcranial dopplers and angiography facilitated the early recognition of vasospasm. Permanent neurologic injury was prevented with the use of hypertensive, hemodilution and hyperdynamic (HHH) therapy along with endovascular treatment, intra-arterial papaverine and angioplasty. Conclusion After uncomplicated treatment of unruptured intracranial aneurysms, the cerebral vasculature may proceed to severe vasospasm by an unrecognized mechanism. This can be reversed with institution of HHH and endovascular therapy. Introduction The major morbidity in patients who survive the initial hemorrhage or rupture from an intracranial aneurysm is cerebral vasospasm. The degree and severity of vasospasm typically correlates with the amount of subarachnoid hemorrhage.1 However, cerebral vasospasm before and after microsurgical treatment of unruptured aneurysms is sparsely reported in the literature*. We report two additional cases, review the existing literature, and illustrate successful treatment with HHH and endovascular therapy.