Subarachnoid Aneurysmal Hemorrhage Associated with Coarctation of the Aorta: Case Report and Review of the Literature

Coarctation of the Aorta as a Rare Indirect Cause of Aneurysmal Subarachnoid Hemorrhage in the Adolescent: A Case Report and Review of the Literature

Aneurysmal subarachnoid hemorrhage (SAH) is rare in teenagers. We present the case of a 19-year-old woman with an aneurysmal SAH and four anterior circulation aneurysms. Due to the urgency of operative treatment, no initial conventional cerebral angiography was performed. The CT angiography depicted the aortic arch incompletely. The coarctation was discovered on day 5 after ictus in a cerebral angiography for vasospasm surveillance. We believe that in young SAH patients without an explainable predilection for aneurysm formation, imaging of the aortic arch during the initial CT angiography, not to miss a coarctation of the aorta, is highly recommended.

Neurological complications in aortic coarctation: Results of a Nationwide analysis based on 11,907 patients

BACKGROUND

Patients with coarctation of the aorta (CoA) are at increased risk of periprocedural and late neurological complications. Based on a nationwide inpatient dataset, we assessed the prevalence and risk factors for neurological complications in this cohort.

METHOD AND RESULTS

We included all CoA patients hospitalized in England between 1997 and 2015. The risk for procedural complications, subarachnoid bleeding and ischemic stroke were quantified, and risk factors investigated. Overall, 11,907 patients (60% male) with CoA were identified. The median age at first presentation was 0.6 years with a median follow-up period of 14.4 years. Throughout the study period, 8456 surgical or interventional procedures were performed in 6796 patients. The neurological complication rate for primary surgical or interventional repair in patients born after 1997 was 0.05% and 0.2%, respectively. During a total follow-up period of 146,295 patient-years, late neurological complications such as subarachnoid bleeding and cerebral infarction occurred in 225 patients (0.15%/patient-year). The median age for subarachnoid bleeding was 29 years and 57 years for ischemic stroke. While, arterial hypertension (p = .0014), current smoking (p = .02), dyslipidaemia (p = .007) and diabetes (p = .037) were significantly related to the risk of ischemic stroke, only arterial hypertension emerged as significant risk factor for subarachnoid bleeding.

CONCLUSIONS

Neurological complication during primary CoA repair are extremely rare in the current era. In contrast, many CoA patients are afflicted by late complications such as subarachnoid bleeding and ischemic stroke at a relatively young age, emphasizing the need for meticulous and pro-active blood pressure control and reduction of cardiovascular risk factors.

Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage

BACKGROUND

Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus.

METHODS

We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes.

RESULTS

A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8).

CONCLUSIONS

Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.