Case report: Intra-procedural aneurysm rupture during endovascular treatment causing immediate, transient angiographic vasospasm

Abstract

Introduction—Cerebral vasospasm is a major cause of delayed ischemic cerebral injury, typically occurring 3–14 days after subarachnoid hemorrhage (SAH). Ultra-early vasospasm is defined as angiographic
vasospasm observed within 48 h of SAH onset. Immediate vasospasm at the time of aneurysmal rupture has
been suspected, but has not been previously reported. We describe a case of immediate, transient vasospasm following intra-procedural aneurysmal rupture.
Methods—A 55-year-old woman presented with SAH from a ruptured anterior communicating artery
aneurysm. Subsequent coil embolization was complicated by an intra-procedural rupture following placement of the initial coil. A follow-up angiogram obtained after 9 min demonstrated moderate-to-severe vasospasm in the A2 segments of both anterior cerebral arteries.
Results—A repeat angiogram 20 min later demonstrated complete resolution of the vasospasm. The
aneurysm was successfully obliterated with coil embolization. Post-procedure, the patient manifested no
clinical vasospasm and made a good neurological recovery.
Conclusion—We document a case of ultra-early cerebral vasospasm that occurred immediately after an
intra-procedural aneurysmal rupture. Catheter-induced vasospasm from mechanical manipulation of extracranial vasculature is well described. However, immediate vasospasm related to extravascular blood has
never before been reported. This finding suggests that extravascular blood can have a local direct effect
(presumably mechanical) on cerebral blood vessels, and may be an important mechanism for vasospasm