A 55-year-old patient presents with a subarachnoid hemorrhage (SAH) secondary to a ruptured middle cerebral artery aneurysm. CT confirms Fischer Grade 3 (thick diffuse subarachnoid blood). On day 7, the patient develops hemiplegia and confusion. TCD shows mean flow velocity in MCA of 160 cm/s. What is this complication and first-line treatment?
- A Re-bleeding; immediate surgical clipping of aneurysm
- B Cerebral vasospasm with delayed cerebral ischemia; treated with triple-H therapy (or hemodynamic augmentation) and nimodipine ✓
- C Hydrocephalus; emergency external ventricular drain placement
- D Hyponatremia from SIADH; fluid restriction
Explanation
Cerebral vasospasm with delayed cerebral ischemia (DCI) is the leading cause of morbidity and mortality after SAH, occurring between days 4–14 (peak day 7–10). Fischer Grade 3 (thick diffuse blood) is the strongest predictor of vasospasm. TCD mean flow velocity > 120 cm/s (or > 200 cm/s for severe spasm) in the MCA confirms vasospasm. Treatment: nimodipine (oral, 60 mg every 4 hours for 21 days) is the only pharmacological agent with proven outcome benefit. Hemodynamic augmentation (induced hypertension, normovolemia) is used for DCI. Cerebral angioplasty/intra-arterial vasodilator therapy (verapamil, papaverine) is reserved for refractory cases.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.