Puerperal Extracranial Vertebral Artery Dissection and Nonaneurysmal Subarachnoid Hemorrhage.

Previously reported only a few times before, we present a case of extracranial vertebral dissection and spontaneous frontoparietal subarachnoid hemorrhage (SAH) in the puerperium, discussing possible mechanisms and difficulties in management. A 35-year-old woman presented 10 days postcaesarean section with neck pain and vertigo with normal initial investigations. Following recurrent vertigo, headache, and ataxia, imaging revealed a frontoparietal SAH and vertebral artery dissection. The patient was consequently treated with aspirin, and then following a return of symptoms 3 weeks later, warfarin therapy was continued for 6 months. The possible underlying mechanisms for this case are discussed, including reversible cervical vasoconstriction syndrome and posterior reversible encephalopathy syndrome, although neither was identified. The small SAH alongside recurrent posterior circulation symptoms resulted in the initiation of antithrombotic therapy. This report supports studies demonstrating higher incidence of cervicocephalic arterial dissection in the puerperium. Moreover, the heterogeneous presentation and manifestations of such cases require individualized treatment, and warrant studies into underlying mechanisms behind extracranial dissection and nonaneurysmal SAH.

Transcranial Doppler as a routine in the treatment of vasospasm following subarachanoid hemorrhage (SAH).

BACKGROUND: Vasospasm is an important complication observed after subarachnoid hemorrhage (SAH) and is a frequent cause of mortality and morbidity. We present our routine management of vasospasm after SAH and emphasize the importance of transcranial Doppler (TCD) ultrasonography in this management. METHOD: Historical records and images were sampled from June 2005 to September 2011 for 110 patients with SAH due to ruptured aneurysm in the anterior circulation. All surviving patients were followed after discharge. Vasospasm was defined as mild (Lindegaard index 3-4), moderate (Lindegaard index 4-5), and severe (Lindegaard index greater than 5). We excluded patients treated after 72 h of symptom onset. TCD was performed twice per day. FINDINGS: Ninety-nine patients had surgical clipping of the aneurysm, and 11 had endovascular treatment. Seventy patients treated by clipping and six treated by endovascular procedure had vasospasm. Of the 70 clipped patients with vasospasm, 40 had mild vasospasm, 13 had moderate vasospasm, and 17 had severe vasospasm. All six patients treated by coils had moderate vasospasm. The average duration of vasospasm was 9 days (from 7 to 32 days). CONCLUSIONS: TCD was crucial for monitoring patients with SAH, and to identify which patients will have a higher risk of developing vasospasm.

Removal of clots in subarachnoid space could reduce the vasospasm after subarachnoid hemorrhage.

BACKGROUND: Cerebral vasospasm after subarachnoid hemorrhage (SAH) is a major cause of morbidity and mortality. We studied the effects of clot removal on multiple outcome variables following the clipping of ruptured anterior communicating aneurysms. METHODS: From 2007 to 2011, 30 patients with Fisher grade III aneurysmal SAH underwent clipping of an anterior communicating artery aneurysm before SAH day 3. There were 20 women and 10 men, mean age 53.4, range 28-80 years. Seventeen underwent fenestration of lamina terminalis and cisternal removal of clots (group A), and 13 did not (Group B). We compared clinical grades, presence of hydrocephalus at admission, treatment modality, occurrence of clinical vasospasm, the need for interventional vasospasm therapy, and need for ventriculoperitoneal shunting. FINDINGS: Vasospasm affected 5 of 17 (29%) in group A and 8 of 13 (61.5%) in group B (p < 0.05). Endovascular treatment for vasospasm was required in one patient in group A (5.8% of 17, 20% of 5) and in five from group B (38.4% of 13, 62.5% of 8) (p < 0.05). Mortality was observed in one case in group A (5.8% of 17, 20% of 5) and in two cases in group B (15.3% of 13, 25% of 8) and was related to vasospasm after SAH. Ventriculoperitonal shunt (VPS) was required in one case in group A (5.8%) and in five cases in group B (38.4%). CONCLUSIONS: Fenestration of the lamina terminalis and removal of cisternal clots significantly decreased the incidence of post-SAH hydrocephalus and was associated with better outcomes in our series.