Ruptured Grade 5 Brain Aneurysm: Case Study of a Patient Who Beat the Odds

A 38-year-old previously healthy woman lost consciousness at home, and her young daughter immediately called for help. When she briefly came to, her speech was slurred and she complained of head pain. By the time emergency medical services arrived, she was comatose. She was rushed by ambulance to nearby Cleveland Clinic Hillcrest Hospital, where she was intubated and underwent a CT scan, which showed subarachnoid hemorrhage (Figure 1).

Because the findings indicated advanced neurological care was needed, she was quickly life-flighted by helicopter to Cleveland Clinic’s main campus. “The patient arrived in extremis,” says Cleveland Clinic neurosurgeon Nina Moore, MD, who admitted her to the cerebrovascular neurosurgery service. “In such cases, we quickly convene a team of neurological specialists to develop a strategy.”

The patient was immediately sent to the operating room, where Dr. Moore emergently placed a drain to alleviate the high intracranial pressure. Cerebral angiography was then performed (Figure 2) to search for a source of the bleed.

Interventional neurologist M. Shazam Hussain, MD, Director of Cleveland Clinic’s Cerebrovascular Center, promptly performed endovascular coiling. Repeat angiography indicated that the aneurysm was filled (Figure 3).

Situation still precarious

Grade 5 aneurysm, the most severe grade in the World Federation of Neurosurgical Societies (WFNS) classification, is defined as being associated with a Glascow Coma Scale score of 3 to 6. It has a 90% fatality rate even with prompt intervention, and survivors are usually left with neurological sequelae.

“These patients must be watched extremely closely and treated aggressively,” says neurocritical care specialist Adam Barron, MD, who was involved with the patient’s initial assessment and led her neurology critical care team.

The patient was kept sedated and given medications to try to reduce brain edema. Dr. Barron stayed in close contact with Dr. Moore and, as pressures worsened, they decided to place a second drain. Despite this, pressures continued to rise, and Dr. Moore next performed a hemicraniectomy.

“The edema seen on CT (Figure 4), despite the presence of two drains and removal of a large piece of skull, was about the worst I’ve ever seen in a patient who ultimately survived,” says Dr. Moore.

Vasospasm develops

The patient stabilized, and although she was still in an induced coma, she had encouraging signs of intact brain function, such as the ability to squeeze her hand on command. However, daily transcranial Doppler ultrasonography revealed that vasospasm was developing, and medications were given to try to address it. Ultrasound and clinical indicators worsened, and on hospital day 4, she was taken in for angioplasty.

Vasospasm, commonly occurring from 3 to 14 days after a subarachnoid hemorrhage, must be treated to prevent a stroke and further neurological deficit. However, Cleveland Clinic interventional neurologist Gabor Toth, MD, explains that every action in such a situation poses a dilemma that requires balancing the need to restore blood flow with the imperative to avoid rupturing the vessel.

“We needed every tool in our toolbox to treat this case,” says Dr. Toth. “As the patient’s condition was so dire, we had to be very aggressive.”

When medications delivered directly to the brain failed to relax the vessel, Dr. Toth performed endovascular balloon dilation. When that also proved inadequate, he deployed a retractable stent-like device, which successfully restored blood flow.

Recovery

Dr. Barron started to slowly wean the patient from medications and allow her to fully regain consciousness. She was extubated on hospital day 9, after which she was soon interacting with family members and her medical team. A speech deficit was evident, as was left-sided weakness.

Physical, occupational and speech therapy programs were started. Drains were removed, and at one month, her bone flap was reattached. Three weeks after admission, she was discharged to a Cleveland Clinic inpatient rehabilitation facility. She returned home two weeks later and continued with outpatient therapy.

Keys to success

“Considering the gravity of her situation, we were all amazed that she survived and how quickly her recovery progressed,” Dr. Moore says. The team credits her favorable outcome to the following:

• Fast and aggressive action. Within the first day of symptom onset, the patient had emergency transportation with life-support capabilities, drain placement and coil embolization. These quick actions and the prompt hemicraniectomy and aggressive treatment of vasospasm were critical to saving this patient and her rapid recovery, Dr. Moore emphasizes.
• Effective communication among specialists. Dr. Barron points out that the unusual multidisciplinary clinical team structure at Cleveland Clinic fosters close working relationships. “My immediate colleagues are vascular neurosurgeons, stroke specialists and endovascular proceduralists,” he says. “In a crisis, you need this spectrum of expertise and high degree of comfortable collaboration to make the best decisions.”
• Vigilance and experience. Dr. Toth notes the importance of consistent vigilance in imaging and clinical monitoring, and the ability to act quickly as a situation changes. “We are fortunate to have the resources we need and a well-oiled machine,” he says. “These include our excellent nurses, respiratory therapists and case managers, who are experienced in handling critical cases.”

Case conclusion

Ten months after her ruptured aneursysm, the patient can walk freely without assistance and is able to drive her daughters to their activities and enjoy cooking and travel again. She is still working on improving speech, and she will continue to be followed with imaging of the aneurysm to monitor for leakage or growth. Family members were informed of their need to manage risk factors.