Transcranial Doppler monitoring after embolization of an unruptured left paraclinoid aneurysm led to detection of subarachnoid hemorrhage

Abstract

A 46-year-old man who presented with an unruptured left paraclinoid aneurysm was treated via endovascular embolization using Guglielmi detachable coils, obtaining its complete exclusion. Within 5 hours, the patient developed a transient mild headache and moderate speech difficulty. CT scans revealed a left temporal ischemic area. Continuous transcranial Doppler monitoring was initiated. Eighteen hours after embolization, the patient developed a mild headache associated with a transient decrease in consciousness, while the diastolic blood flow velocity decreased and the pulsatility index increased in the left middle cerebral artery. These changes prompted us to perform CT, which revealed a subarachnoid hemorrhage. Angiograms demonstrated partial revascularization of the newly embolized aneurysm. The patient underwent a second embolization procedure with additional coils for complete exclusion of the aneurysm. His postoperative course was uneventful, with no additional neurological deficits. Although TCD monitoring is not recommended as a routine procedure in such cases, and experimental studies are needed to evaluate the possible risk of rebleeding in this specific setting, it could be used to detect the hemodynamic consequences of an acute increase in intracranial pressure, as in patients at risk of subarachnoid hemorrhage after endovascular treatment.