Bamimore Michael A, Lee Seung J, Perez Vega Carlos, Brown Nolan, Gendreau Julian L, Al Shaikh Rana Hanna, Jeevaratnam Suren, Freeman William D
Department of Neurological Surgery, Mayo Clinic, Jacksonville, USA.
Department of Neurological Surgery, University of California Irvine, Orange, USA.
Cureus. 2023 Jan 1;15(1):e33217. doi: 10.7759/cureus.33217. eCollection 2023 Jan.
Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high patient mortality. Despite recent advances in management strategies, the prognosis for poor-grade aSAH remains dismal. We present a challenging case of a patient presenting with poor-grade aSAH. A 46-year-old female presented to the emergency department after losing consciousness following a sudden headache. The examination showed a dilated left pupil and a Glasgow Coma Scale of 4. Imaging revealed a ruptured anterior communicating artery (ACoM) aneurysm, after which the patient was subsequently taken to the neuro-interventional radiology suite. We showed that carefully managing blood pressure and intracranial pressure (ICP) makes it possible to achieve a favorable outcome and reduce the risk of secondary brain injury in aSAH, regardless of patient presentation. We propose maintaining blood pressure at <160 mmHg prior to intervention, after which it can be permitted to increase to 160-240 mmHg for the purpose of preventing vasospasm. Additionally, transcranial doppler (TCD) is essential to detect vasospasm due to the subtility of symptoms in patients with aSAH. Once identified, vasospasm can be successfully treated with balloon angioplasty. Finally, targeted temperature management (TTM), mannitol, hypertonic saline, and neuromuscular paralysis are essential for the postoperative management of ICP levels.
低级别动脉瘤性蛛网膜下腔出血（aSAH）与患者高死亡率相关。尽管管理策略最近有所进展，但低级别aSAH的预后仍然不佳。我们展示了一例具有挑战性的低级别aSAH患者病例。一名46岁女性在突发头痛后失去意识，被送往急诊科。检查显示左侧瞳孔散大，格拉斯哥昏迷量表评分为4分。影像学检查发现前交通动脉（ACoM）动脉瘤破裂，随后该患者被送往神经介入放射科。我们表明，无论患者表现如何，仔细管理血压和颅内压（ICP）能够实现良好预后并降低aSAH患者继发性脑损伤的风险。我们建议在干预前将血压维持在<160 mmHg，之后为预防血管痉挛可允许血压升至160 - 240 mmHg。此外，由于aSAH患者症状隐匿，经颅多普勒（TCD）对于检测血管痉挛至关重要。一旦确诊，血管痉挛可通过球囊血管成形术成功治疗。最后，目标温度管理（TTM）、甘露醇、高渗盐水和神经肌肉麻痹对于术后ICP水平的管理至关重要。
