A 61-year-old Hispanic male was transferred from an outside facility when he was found by his wife after falling in the bathroom earlier that morning. At the outside institution, he reportedly had a GCS of 8 (unknown breakdown) and was for declining mental status. CT head demonstrated prominent SAH in the basal cisterns [Figure 6] and CTA demonstrated a bilobed anterior communicating artery aneurysm [Figure 7]. Clinical grades demonstrated HH4+1 and mFG4. His medical history was significant for hypertension, previous craniotomy from a gunshot wound to the head, prior heroin abuse, and hepatitis C. He had tested positive for COVID-19 approximately 2 weeks before admission, though asymptomatic. Baseline MRS was 0 with no family history of aneurysms.
On arrival to our institution, he was afebrile, with BP 164/100 mmHg and saturating 100% on 40% FiO2. Clinically, he was intubated with a GCS of 8T (e2vTm5), with a prosthetic right eye but otherwise with intact cranial nerves. He was localizing to pain in his left upper extremity and withdrawing in all other extremities. Laboratory values were significant for leukocytosis of 18.0 10e9/L and sodium 135 mEq/L. Liver function test and coagulation were within normal limits. A right frontal ventriculostomy was placed and he was started on levetiracetam, nimodipine, and high-dose rosuvastatin for vasospasm protection.
On postbleed day 1, he was taken to the interventional suite for coiling. Diagnostic angiography of the left ICA revealed a large multilobulated bulbous aneurysm of the anterior communicating artery [Figure 8]. Coil embolization was successful with complete aneurysm obliteration with minimal contrast filling along the neck and no evidence of occlusion of either the communicating segment or the distal A2's or proximal A1 segments right and left sides [Figure 9].
Postprocedure, the patient returned intubated to the ICU with a stable neurological examination. He was successfully extubated on hospital day 2 and spiked a fever on hospital day 5-38.4 C, but otherwise remained afebrile during his hospital course. Ventricular drain weaning was unsuccessful and a right frontal ventriculoperitoneal shunt was placed on hospital day 20. He was downgraded from the ICU on hospital day 22 with no evidence of vasospasm. Clinically, he was a GCS of 14, e4v4m6. He would intermittently converse but remained confused. Cranial nerves were intact and he would intermittently follow simple commands in all extremities with no lateralizing motor deficits.