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Difficulty: MediumNeurosurgery

A 52-year-old woman is evaluated in the neurosurgical intensive care unit for new-onset neurological deficits. Six days ago, she was admitted for a subarachnoid hemorrhage and underwent successful endovascular coiling of a ruptured anterior communicating artery aneurysm. Her postoperative course was initially uncomplicated, and she has been receiving standard medical therapy. Over the past 2 hours, she has become increasingly lethargic and developed right-sided weakness. Her temperature is 37.2°C (99.0°F), blood pressure is 112/72 mm Hg, and pulse is 84/min. Physical examination confirms right-sided hemiparesis and expressive aphasia. A noncontrast CT scan of the head reveals the coiled aneurysm with no new bleeding, hydrocephalus, or territorial infarction. Which of the following is the most appropriate next step in management?

  1. A
    Administration of intravenous nimodipine
  2. Induction of hypertension with intravenous vasopressorsAnswer
  3. C
    Immediate return to the operating room for surgical decompression
  4. D
    Transport for a magnetic resonance imaging of the brain
  5. E
    Administration of broad-spectrum intravenous antibiotics

Answer

The most appropriate next step is the induction of hypertension with intravenous vasopressors.
The correct answer is to induce hypertension with intravenous vasopressors. This patient is experiencing delayed cerebral ischemia due to vasospasm, which is a classic complication occurring 3 to 10 days after a subarachnoid hemorrhage. The standard of care for symptomatic vasospasm, once rebleeding and hydrocephalus have been excluded by CT, is hemodynamic augmentation. Inducing hypertension increases cerebral perfusion pressure across the narrowed vessels, preventing permanent ischemic stroke.

Step-by-Step Solution

1
Analyze the patient's timeline and clinical presentation.
The patient developed acute focal neurological deficits (hemiparesis, aphasia) on day 6 following a subarachnoid hemorrhage.
Identifying the timeline after subarachnoid hemorrhage is critical, as vasospasm typically occurs between days 3 and 10 (peaking at days 5 to 7).
2
Interpret the neuroimaging findings.
The noncontrast CT scan shows no new bleeding, hydrocephalus, or infarction.
This rules out rebleeding (most common in the first 24 hours) and hydrocephalus, confirming symptomatic cerebral vasospasm as the underlying cause of the neurological deterioration.
3
Determine the appropriate management for symptomatic vasospasm.
The correct management is hemodynamic augmentation via induced hypertension.
Increasing systemic blood pressure overcomes the cerebrovascular resistance caused by the vasospasm, thereby maintaining cerebral perfusion and preventing permanent ischemic infarction.

Key Concept

Cerebral vasospasm is a major delayed complication of subarachnoid hemorrhage that typically presents 3 to 10 days post-hemorrhage. When suspected, and structural causes are ruled out, the immediate treatment is hemodynamic augmentation (induced hypertension) to improve cerebral perfusion.
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Neurosurgery

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