What is the next step in managing a female patient with a history of diffuse subarachnoid hemorrhage (SAH) due to bilateral internal carotid artery (ICA) aneurysms, one of which was stented, who developed left-sided body weakness after extubation?

Management of New Left-Sided Weakness Post-Extubation in SAH Patient with Stented ICA Aneurysm

Obtain an urgent non-contrast head CT immediately to differentiate between ischemic stroke (from in-stent thrombosis or vasospasm), hemorrhagic transformation, or new hemorrhage, followed by CT angiography or digital subtraction angiography to assess stent patency and evaluate for delayed cerebral ischemia. 1

Immediate Diagnostic Workup

The development of new focal neurological deficits after aneurysm treatment in a SAH patient represents a medical emergency requiring rapid evaluation:

• Perform immediate non-contrast head CT to exclude hemorrhagic complications, hydrocephalus, or hemorrhagic transformation 1, 2
• Follow with CT angiography or DSA to assess:
  • Stent patency and potential in-stent thrombosis
  • Vasospasm in other vessels
  • Aneurysm remnant or rebleeding
  • Delayed cerebral ischemia (DCI) 1, 2

Critical timing consideration: The patient is in the window for delayed cerebral ischemia, which typically occurs between days 4-12 but can extend beyond, making this evaluation time-sensitive 3, 1

Differential Diagnosis Priority

The most likely etiologies in order of urgency are:

1. In-stent thrombosis - Given recent stent placement, this is a high-risk complication requiring immediate antiplatelet assessment
2. Delayed cerebral ischemia/vasospasm - Common complication affecting up to 30% of SAH patients 1
3. Hemorrhagic transformation or new hemorrhage
4. Hydrocephalus with mass effect

Immediate Management Pending Imaging

Hemodynamic Optimization

• Maintain mean arterial pressure >90 mmHg to ensure adequate cerebral perfusion, particularly if DCI is suspected 3, 1
• Avoid hypotension (MAP <65 mmHg) at all costs, as this compromises cerebral perfusion and worsens ischemia 3
• Use titratable vasopressors if needed to maintain cerebral perfusion pressure 1, 2
• Establish arterial line monitoring for beat-to-beat blood pressure tracking 3

Antiplatelet Status Assessment

• Verify antiplatelet therapy compliance - Patients with stented aneurysms typically require dual antiplatelet therapy (aspirin plus clopidogrel)
• Consider platelet function testing if available to assess antiplatelet effect
• Do NOT discontinue antiplatelets unless life-threatening hemorrhage is identified

Management Based on Imaging Findings

If In-Stent Thrombosis Identified:

• Urgent neurointerventional consultation for potential mechanical thrombectomy or intra-arterial thrombolysis
• Optimize antiplatelet therapy with loading doses if not contraindicated
• Maintain aggressive blood pressure support to maximize collateral flow 1

If Vasospasm/DCI Identified:

• Induce hypertension as first-line therapy unless baseline blood pressure is already elevated or cardiac status precludes it 1, 3
• Maintain euvolemia through goal-directed fluid management; avoid prophylactic hypervolemia as it does not improve outcomes 1, 3
• Consider endovascular therapy (intra-arterial vasodilators or angioplasty) if medical management fails 1

If New Hemorrhage or Hydrocephalus:

• Urgent neurosurgical consultation for potential external ventricular drainage placement 1
• Control blood pressure to prevent hematoma expansion while maintaining cerebral perfusion 1, 2

Ongoing Monitoring and Supportive Care

• Continuous neurological examination to detect progression or improvement 3
• Maintain nimodipine 60 mg every 4 hours if already initiated (improves neurological outcomes in SAH) 1, 2
• Correct electrolyte abnormalities, particularly hypomagnesemia which is common after SAH 3
• Aggressively manage fever and hyperglycemia, as these are independent predictors of poor outcome 3

Critical Pitfalls to Avoid

• Do not delay imaging - New deficits require immediate evaluation as the therapeutic window for intervention is narrow 1, 2
• Do not allow hypotension - This is particularly dangerous in the setting of potential DCI or in-stent thrombosis 3
• Do not assume the deficit is from the stented aneurysm alone - The patient has bilateral ICA aneurysms and diffuse SAH, making multiple etiologies possible 1
• Do not discontinue antiplatelet therapy precipitously - Stent thrombosis carries extremely high morbidity and mortality

Multidisciplinary Team Involvement

Immediate consultation with neurosurgery and neurointerventional services is mandatory, as patients with SAH should be managed by a multidisciplinary team including neurosurgeons, neurointerventionalists, and neurointensivists 1, 2