1372. Best Laid Plans—Illicit Drug Use Resulting in Devastating Post-Aneurysmal SAH Vasospasm

Authors: Gary Robert Simonds, MD, FAANS; Eric Marvin; Andrew Nicholson; Chris Busch; Michael Benko; Brendan Klein; Brian Saway (Black Mountain, NC)

Introduction: Despite striking advances in treatment, ruptured cerebral aneurysms continue to present a vexing challenge to neurosurgeons. Initial management via open surgery or endovascular therapy may go remarkably smoothly only to be turned upside-down by the sometimes inescapable complications of the disease. We have made significant ground in the management of dreaded vasospasm, but sometimes we are still at the mercy of the disease. Sometimes, this troubling problem can be compounded by the medical status of the patient. On occasion, it can even be torpedoed by the behavior of the patient. Methods: We describe a patient presenting with a basilar aneurysm aneurysm who survived her hospital course without major deficits, but potentially precipitated her own major complication after discharge. We will review this case and related literature, and discuss its medical, legal, and socio-economic implications. Results: The patient is a 35 year old female with a history of profound substance abuse. She sustained a Hunt Hess 2, Fisher Grade 4 subarachnoid hemorrhage from a basilar tip aneurysm. The aneurysm was successfully treated via coil embolization. The patient recovered well with no deficits. On the day of discharge, upon arriving home, the patient began taking illicit substances. Shortly thereafter she developed total blindness from bilateral PCA infarcts. Subsequent arteriography demonstrated profound bilateral PCA spasm. The spasm was aborted via endovascular techniques but the patient's vision did not improve. Conclusion: This patient sustained delayed and profoundly detrimental vasospasm after subarachnoid hemorrhage, presumably secondary to the abuse of potentially vasoactive substances. The patient had been warned specifically to refrain from such behavior on discharge. None of the treating team had experienced this type of complication related to such behavior. We recommend aggressive substance abuse counseling and intervention for these types of patients prior to release to their own recognizance.