Abstract

Presentation of aneurysmal subarachnoid hemorrhage is often dramatic, and the management is even more challenging especially in a resource poor setting. There is therefore not a lot of local experience in the contemporary management of this inherently fatal form of stroke. This article shares our local experience in managing this condition in a resource constrained environment.

Aims and objectives: To report a four years’ experience in managing aneurysmal subarachnoid hemorrhage in Abuja, North Central Nigeria.

Methodology: Retrospective review of all cases that presented with CT confirmed aneurysmal subarachnoid hemorrhage from Jan 2016 to Jan 2020. Those with typical history of SAH, but unable to conduct these investigations were excluded. The biodata, clinical process, management and outcome were reviewed. Data generated were analyzed with simple descriptive statistics and presented accordingly.

Result: Only 27 (47%) patients out of 57 were sampled. 11 males and 16 females (M: F= 0.69: 1). Age range 26 -68 years. Mean age 46.4 years (SD=10.9). The shortest time to presentation was 4 hours, longest time to presentation was 168 days (Mean 26 days, SD 53.9 days). The commonest presenting complaints were headache 23/27 (85.1%), impairment of consciousness 14/27 (51.8%), Seizure 9/27 (33%). WFNS Grade 1 was the commonest presentation 12/27 (44%). The commonest observed risk factor was systemic hypertension in 18/27 (66.6%). The average mean arterial blood pressure was 115 mmHg, range 83.3-183, SD-26.9mmHg. Commonest was PCOM aneurysm 9/27 (33%) followed ACOM aneurysm 8/27 (29.6%). Intraventricular hemorrhage and associated acute obstructive hydrocephalus were observed in 12/27(44.4) requiring initial external ventricular drain EVD in 7/12 (58.3%) cases. The commonest operation was craniotomy for clipping in 15/27 (55.5%) followed by endovascular coiling in 3/27 (11.1%) Four (14.1%) rebled and died while awaiting definitive treatment, two (7.4%) are still awaiting treatments. Common surgical complications were extradural hematoma 4/15 (26.6%), Delayed ischemic neurological deficit (vasospasm) was observed in 3/27 (11.1%) especially in the post-surgical group. Rebleed was perhaps the most important because it caused a fatality. In one case hemiparesis and in another transient aphasia were recorded. Modified Rankin score was optimal in endovascularly coiled cases and in 13/27 (86.6%) of surgically clipped. 1/15(6.6%) died 48hrs while another (6.6%) was mRs 4 and required sustained support. Three were found to be non-aneurysmal perhaps from venous peri-mesencephalic bleed while two were confirmed aneurysmal bleeds but presently economically constrained to fund their planned surgical clipping since more than a year.

Conclusion: The numbers are small, but the study demonstrated sheer determination to treat brain aneurysms despite the great constraints. The experience gathered therefrom provides a high pedestal to achieve more in a better enabled environment.

Keywords: Cerebral aneurysms; Subarachnoid hemorrhage; Surgical clipping; Coiling