Unruptured Aneurysm: Vasospasm after Surgery and Endovascular Treatment

Summary

Arterial cerebral vasospasm in different pathological conditions other than subarachnoid haemorrhage (SAH) caused by ruptured aneurysm is uncommon. The haemodynamics-clinical consequences of such conditions makes a quick diagnosis, vital to choose the best therapeutic strategy.

A 55-year-old woman presented chronic headache. Computed tomography scan revealed an image suggesting carotid aneurysm on the left which was confirmed by digital angiography in the ophthalmic segment. Programmed surgery of clipping aneurysm was carried out without complications. The patient remained without morbidity for the first 16 hours, then she developed progressive aphasia, right motor deficit and loss of consciousness.

The angiography showed severe vasospasm in horizontal segments of anterior cerebral artery (Al) and middle cerebral artery (Ml). Vasodilatation with topic papaverine by selective microcatheterism in Al and MI segments achieved clinical-radiological success in time. The patient was discharged on the seventh day, with Glasgow Coma Scale (GCS) 15/15 and slight right hemiparesis.

Vasospasm pathogenesis in conditions other than SAH from ruptured aneurysm remains a scientific frontier for ongoing research.

We know about the short half-life effect of papaverine and believe that the success in this particular case was accurate and definite due to the fact that the mechanism of the spasm presented no bleeding in the subarachnoid cisterns.

Introduction

Arterial spasm is produced by a reduction of the endoluminal diameter of the artery. Basically, there are two ways of defining vasospasm, one being complementary to the other: angiographic spasm, where an image is observed in narrow pass with scarce reception of the contrast, and clinical spasm affecting the compromised segments and its consequent vascular insufficiency.

Cerebral vasospasm after meningeal haemorrhage is common to observe. The proposed mechanisms to develop contraction of the media muscular wall are vasoconstriction agents found in arterial haemorrhage, vasoactive agents in CSF, neuronal mechanisms by nervorum vasa injury, endothelial relaxing factor inhibition (EDRF), inflammatory, inmunoreactive and mechanic processes.

Less common are arteriovenous malformation vasospasm, head trauma, intracranial tumour resection associated with purulent and tuberculous meningitis, ophthalmoplegic migraine, hypertensive encephalopathy, arteriolar embolisation or removal of an embolus from the MCA, myelography, eclampsia, electroconvulsive therapy, and with unruptured and sometimes unoperated anueurysm^7,8,10.

The presence of different pathological states in association with vasospasm indicates that diverse triggering mechanisms exist, some being more common with this phenomenon⁵.

The treatment of such haemodynamic condition can be carried out with calcium channel blockers, hyperdynamic therapy, chemical arterial vasodilatation, and/or angioplasty⁷.

We report a case of 55-year-old woman who developed a severe vasospasm during a postoperative period of unruptured aneurysm without surgical complications.

Case Report

A 55-year-old woman presented chronic headache. The computed tomography scan (CT) showed an image compatible with carotid aneurysm on the left without evidence of SAH. This diagnosis was confirmed by digital subtraction angiography (DSA) on the left ophthalmic artery topography of 3 mm by 5 mm and a 2 mm neck (figure 1A). Surgery was programmed 30 days after the diagnosis, her clinical condition being eminently good. During surgery it was not necessary to place an obstruction ball or carry out aspiration of the aneurysm sac and no complications were encountered. During recovery from anesthesia and the first 16 hours in intensive therapy, she remained in a Glasgow Coma Scale (GCS) of 14, without neurological deficits. Next she developed severe right hemisparesis, aphasia and coma.

Figure 1.

DAS demonstrating a carotid-ophthalmic aneurysm (A) and post-surgical CT (B) without SAH.

The CT did not reveal any structural alteration compatible with the clinical symptoms (figure 1B), the angiography showed severe vasospasm in topography Ml, M2 and A1 and A2 (figure 2A).

Figure 2.

DSA with vasospasm (A) and after super-selective papaverine instillation (B) with recovery of normal vessel caliber.

Microcatheterism of these arterial structures was carried out with papaverine instillation observing immediate anatomical improvement and clinical recovery (figure 2B). The patient was discharged on the seventh day with GCS 15/15, and slight right hemiparesis.

Discussion

This case in particular suggests a brief review of all published cases of unruptured aneurysm clipping and on other pathological conditions where no subarachnoid bleeding is noted and which are capable of provoking arterial cerebral spasm ^{1,3,5,6,8,9,10}.

The mechanisms that suggest postsurgical vasospasm are related to the topographic localization of the aneurysm sac next to the midline on the hypothalamus, demonstrating the theory that surgical manipulation affecting this area can provoke vasospasm as in this ophthalmic segment aneurysm ⁸.

The typical treatments for this type of spasm are poorly effective.

Endovascular therapy like angioplasty is not applicable to these cases due to the non-existence of segmentary stenosis showing it as diffuse narrowing.

The treatment applied in this case was chemical intra-arterial, in spite of its fleeting effect. The therapy was successful, and therefore explained by the fact that without haemorrhage or some other cause able to produce persistent vasospasm, appropriate treatment is achieved.