Delayed cerebral ischemia after clipping of middle cerebral artery aneurysms

Background: Delayed cerebral ischemia (DCI) that occurs more than 14 days after clipping of middle cerebral artery (MCA) aneurysms is rare.

Objective:To investigate whether multiple treatments that prevent vasospasms and microthrombosis may achieve a better outcome for DCI.

Method: We present three cases of subarachnoid hemorrhage (SAH) in patients who experienced DCI before and after MCA aneurysmal clipping. Their clinical manifestations, neuroradiological aspects, treatment, and outcomes are presented. Digital subtraction angiograms and computed tomographic angiography were performed to confirm the MCA aneurysms. Aneurysmal clippings were implemented via a pterional approach within 3 days of the onset of SAH. Triple-H therapy was conducted, and nimodipine was administered intravenously. The three patients were released with intact neurological status within 14 days to 17 days of clipping.

Results: The three patients were readmitted within 7 days after discharge because of cerebral ischemia in the corresponding MCA area. Antiplatelet drugs were administered with resolution of clinical symptoms within a few days.

Conclusion: The occurrence of this kind of DCI is rare. The pathogenesis of DCI is unknown and may be complex. Multiple treatments that prevent vasospasms as well as microthrombosis may achieve a better outcome.