Great job! This was a challenging case from a management perspective. The patient developed symptomatic vasospasm, but the presence of a second aneurysm could have limited our ability to treat this. Her cardiac function, perhaps secondary to an OMI, also could've limited our options. This case is a great example of how it's important to recognize and appreciate the multiple organ system dysfunction and how treating one organ can negatively impact the other, sometimes resulting in an overall net negative result.
Clinical manifestations of vasospasm are more easily recognized when they're very clearly focal. For example, if a patient suddenly becomes aphasic, and we find severe left MCA vasospasm on vessel imaging. However, we can't forget that a diminished level of consciousness can also indicate either basilar vasospasm or bilateral anterior circulation vasospasm.
We don't know definitively whether treatment with endovascular therapy or BP augmentation improves functional outcomes. The available data is promising, but further investigation is needed. As long as patient circumstances allow it, it is worthwhile to try one or both of these options when considering the downsides of not pursuing therapy.
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