Cerebral vasospasm and delayed ischaemic deficit following elective aneurysm clipping. (December 2016)

• Record Type: Journal Article
• Authors: Tsyben, Anastasia; Paldor, Iddo; Laidlaw, John
• Is Part Of: Journal of clinical neuroscience. Volume 34(2016:Dec.)
• Page Start: 33
• Page End: 38
• Publication Date: 2016-12
• Subjects: Clipping -- Delayed ischaemic deficit -- Intracranial aneurysm -- Unruptured aneurysm -- Vasospasm; Brain -- Surgery -- Periodicals; Neurosciences -- Periodicals; Nervous system -- Surgery -- Periodicals; Brain -- surgery -- Periodicals; Neurosurgical Procedures -- Periodicals; Neurosciences -- Periodicals; Electronic journals; 616.8
• DOI: 10.1016/j.jocn.2016.06.006
• Languages: English
• ISSNs: 0967-5868

Abstract

Highlights: Cerebral vasospasm (CVS) and delayed ischaemic neurological deficit (DIND) are common after subarachnoid haemorrhage. CVS and DIND, however, are rarely reported after elective clipping for unruptured aneurysms. The mechanisms underlying both CVS and DIND are multifactorial. Both CVS and DIND are potentially treatable, and delay or failure of treatment is likely to result in adverse outcome. Abstract: Although common after subarachnoid haemorrhage, cerebral vasospasm (CVS) and delayed ischaemic neurological deficit (DIND) rarely occur following elective clipping of unruptured aneurysms. The onset of this complication is variable and its pathophysiology is poorly understood. We report two patients with CVS associated with DIND following unruptured aneurysmal clipping. The literature is reviewed and the potential mechanisms in the context of patient presentations are discussed. A woman aged 53 and a man aged 70 were treated with elective clipping of unruptured middle cerebral artery aneurysms, the older patient also having an anterior communicating artery aneurysm clipped. The operations were uncomplicated with no intra-operative bleeding, no retraction, no contusion, no middle cerebral artery (MCA) temporary clipping, and no intra-operative rupture. Routine post-operative CT scan and CT angiogram showed that in both patients the aneurysms were excluded from the circulation and there was no perioperative subarachnoid blood. Both patients had no neurological deficit post-operatively, but on day 2 developed DIND and vasospasm of the MCA. Both patients had angiographic improvement with intra-arterial verapamil treatment. In one patient, this was done promptly and the patient made a complete recovery, but in the other, the diagnosis was delayed for more than 24 hours and the patient had residual hemiparesis and dysphasia due to MCA territory infarction. CVS and DIND following treatment of unruptured aneurysms is a very rare event. However, clinicians should be vigilant as prompt diagnosis and management is required to minimise the risk of cerebral infarction and poor outcome.