Symptomatic Vasospasm Refractory to Clazosentan after Subarachnoid Hemorrhage of Ruptured Vertebral Artery Dissecting Aneurysm: Clinical Implications from Two Contrasting Cases

• Published in: Medicina (Kaunas, Lithuania) Vol. 60; no. 9; p. 1543
• Main Authors: Yoshida, Yasuyuki, Mutoh, Tatsushi, Moroi, Junta, Ishikawa, Tatsuya
• Format: Journal Article
• Language: English
• Published: Switzerland MDPI AG 20.09.2024; MDPI
• Subjects: Aneurysm, Ruptured - complications; Aneurysms; Case Report; Case reports; Causes of; cerebral vasospasm; Cerebrovascular spasm; clazosentan; Clinical outcomes; Complications and side effects; computed tomography; Consciousness; CT imaging; Dioxanes - therapeutic use; Drug therapy; Endovascular Procedures - methods; Glasgow Coma Scale; Headaches; Hemorrhage; Humans; Hydrocephalus; Ischemia; Male; Medical imaging; Medical prognosis; Middle Aged; Patients; Pyridines - therapeutic use; Pyrimidines - therapeutic use; Retrospective Studies; Stroke (Disease); Subarachnoid hemorrhage; Subarachnoid Hemorrhage - complications; Subarachnoid Hemorrhage - drug therapy; Sulfonamides - therapeutic use; Tetrazoles - therapeutic use; Tomography; Vasospasm, Intracranial - complications; Vasospasm, Intracranial - diagnostic imaging; Vasospasm, Intracranial - drug therapy; Vasospasm, Intracranial - etiology; Veins & arteries; vertebral artery dissecting aneurysm; Vertebral Artery Dissection - complications; Vertebral Artery Dissection - drug therapy; Japan; computed tomography; vertebral artery dissecting aneurysm; clazosentan; cerebral vasospasm; subarachnoid hemorrhage
• ISSN: 1648-9144; 1010-660X; 1648-9144
• DOI: 10.3390/medicina60091543

Clazosentan prevents vasospasms after aneurysmal subarachnoid hemorrhage (SAH). However, clinical data on patients with SAH with ruptured vertebral artery dissecting aneurysms (VADAs) are limited. We report the case of a 49-year-old male patient with mild-grade (WFNS grade 1) thick and diffuse (modified Fisher grade 3) SAH who underwent endovascular trapping of a ruptured VADA, resulting in a poor functional outcome with a modified Rankin Scale score of 4 due to severe symptomatic vasospasm refractory to clazosentan, requiring repeated rescue endovascular therapies and chronic communicating hydrocephalus. A retrospective analysis of the clot density in the basal and Sylvian cisterns, assessed by the Hounsfield unit (HU) values of serial CT scans, in this patient showed persistent higher values, distinct from another VADA case that showed a decline in HU values with a good clinical course. These results imply the limited effectiveness of clazosentan in cases of thick and diffuse SAH after a ruptured VADA, even in good-clinical-grade patients treated with less invasive modalities. The HU values may become a simple quantitative marker for predicting symptomatic vasospasms and chronic hydrocephalus.