Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA.
Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA.
World Neurosurg. 2020 Sep;141:52-58. doi: 10.1016/j.wneu.2020.05.235. Epub 2020 May 31.
Cerebral vasospasm and delayed ischemic neurologic deficits are well-known clinical aftereffects of subarachnoid hemorrhage due to rupture of an intracranial aneurysm. However, vasospasm with consequential ischemia after clipping of an unruptured aneurysm is an exceedingly rare sequela encountered in the reported neurosurgical literature.
A 53-year-old woman had presented for elective craniotomy with microsurgical clipping of an unruptured left middle cerebral artery bifurcation saccular aneurysm, which was successfully treated without complications. Despite an initially benign clinical course, she experienced diffuse vasospasm with profound ischemic neurologic deficits on postoperative day 13 with a left middle cerebral artery distribution ischemic infarct. Moreover, she developed recurrent delayed spasm of the right posterior cerebral artery on postoperative day 26 and, consequentially, a left homonymous hemianopsia despite treatment with intra-arterial verapamil infusion.
To the best of our knowledge, we have reported the first case of recurrent cerebral vasospasm and delayed ischemia neurologic deficits weeks subsequent to clipping of an unruptured aneurysm. The findings from the present case highlight the importance of considering delayed vasospasm as a cause of acute onset neurologic symptoms for patients who have recently undergone elective aneurysm surgery. We also reviewed the current data regarding the epidemiology, surgical factors, and proposed pathophysiologic mechanisms related to vasospasm after elective cases.
蛛网膜下腔出血后，由于颅内动脉瘤破裂，会出现脑血管痉挛和迟发性缺血性神经功能缺损等已知的临床后遗症。然而，夹闭未破裂的动脉瘤后出现血管痉挛和随之发生的缺血是在已报道的神经外科文献中非常罕见的后续并发症。
一名 53 岁女性因左侧大脑中动脉分叉部囊状动脉瘤行择期开颅显微夹闭术，手术过程顺利，无并发症。尽管最初的临床病程良好，但她在术后第 13 天出现弥漫性血管痉挛，伴有严重的缺血性神经功能缺损，左侧大脑中动脉分布区域发生缺血性梗死。此外，她在术后第 26 天出现右侧大脑后动脉反复迟发性痉挛，尽管进行了动脉内维拉帕米输注治疗，仍导致左侧同向性偏盲。
据我们所知，我们报告了首例夹闭未破裂动脉瘤数周后发生复发性脑血管痉挛和迟发性缺血性神经功能缺损的病例。本病例的结果强调了对于近期接受择期动脉瘤手术的患者，应考虑迟发性血管痉挛是急性发作性神经症状的原因。我们还回顾了目前与择期病例后血管痉挛相关的流行病学、手术因素和提出的病理生理机制的相关数据。
