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SAH Vasospasm — FRCA Final MCQ

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ModerateNeuroanaesthesiaSAH VasospasmFRCA Final

A 50-year-old woman is admitted to ICU following aneurysmal subarachnoid haemorrhage (WFNS grade II). The aneurysm has been secured by coiling, and enteral nimodipine has been commenced. On day 5 she develops new left arm weakness. Oxygenation, blood glucose and serum sodium are normal, and there has been no witnessed seizure. Non-contrast CT shows no rebleeding, hydrocephalus or new mass lesion; CT angiography demonstrates marked narrowing of the right middle cerebral artery. What is the most likely diagnosis and appropriate initial management?

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Correct answer: D — Delayed cerebral ischaemia associated with vasospasm – ensure euvolaemia and consider vasopressor-induced hypertension if the deficit persists

The correct answer is D. A new focal deficit on day 5 after aneurysmal SAH, after exclusion of metabolic disturbance, rebleeding and hydrocephalus, with corresponding arterial narrowing is characteristic of delayed cerebral ischaemia associated with vasospasm. Initial management is haemodynamic optimisation: ensure euvolaemia and, if the neurological deficit persists, consider a vasopressor to raise systemic arterial pressure and cerebral perfusion. Enteral nimodipine should be continued, but it is principally used to reduce the risk of poor neurological outcome rather than as sole rescue treatment for an established deficit. Traditional triple-H therapy is obsolete: prophylactic hypervolaemia and haemodilution offer no established benefit and can cause cardiopulmonary harm. CT excludes rebleeding and hydrocephalus, while the absence of seizure activity and the demonstrated arterial narrowing make postictal paresis less likely. Mannitol is not indicated without evidence of intracranial hypertension.

Reference: NICE guideline NG228, Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management, recommendations 1.3.2 and 1.3.6, 2022. https://www.nice.org.uk/guidance/ng228/chapter/Recommendations