A clinical case of combined treatment of a patient with massive aneurysmatical subarachnoid and intraventricular hemorrhage

   Massive aneurysmal subarachnoid h emorrhage (aSAH) is a life-threatening, severe condition with a mortality rate of over 30 % and associated with poor outcomes among survivors. Only 30 % of patients after aSAH are able to return to independent living.

   The aim of the study – to report a clinical case of combined treatment of a patient with massive aSAH with a satisfactory clinical outcome.

   A 51-year-old patient with a massive aneurysmal parenchymatous-ventricular-subarachnoid hemorrhage and basal cistern tamponade, along with blood leaking into the ventricular system from a supraclinoid aneurysm of the right internal carotid artery, is reported. The patient underwent two surgeries: the first stage was decompressive craniotomy and clipping of the supraclinoid aneurysm of the right ICA, during which a recurrent intraoperative rupture of the aneurysm was noted. The second stage involved partial ablation of the intraventricular hematoma and placement of an external ventricular drain in the anterior horn of the right lateral ventricle. A fibrinolytic agent (tissue plasminogen activator) was also administered intraventricularly through the external ventricular drain. As a result, a satisfactory clinical outcome was achieved two months after onset. The Expanded Glasgow Outcome Scale (eCGS) score was 5, the Modified Rankin Scale (MRS) score was 3, and the Rivermead Mobility Index (RMI) score was 7. Improving treatment outcomes for aSAH requires a multidisciplinary, specialized, individualized approach, which is best provided in large, specialized centers.

1. Eliava Sh. Sh., Pilipenko Yu.V., Belousova O.B., et al. Surgical treatment of intracranial aneurysms in acute period of hemorrhage in Hunt–Hess grade IV–V patients at Burdenko Neurosurgical Center between 2006 and 2020. Burdenko’s Journal of Neurosurgery. 2023;87(6):5–13. (In Russ.). Doi: 10.17116/neiro2023870615

2. Krylov V. V., Éliava Sh. Sh., Yakovlev S. B., Kheireddin A. S., Belousova O. B., Polunina N. A. Clinical guidelines for treatment of unruptured asymptomatic brain aneurysms. Burdenko’s Journal of Neurosurgery. 2016;80(5):124–135. (In Russ.). Doi: 10.17116/neiro2016805124-135.

3. Kornev A. P., Ermakov S. V., Rozhchenko L. V ., Belokon O. S., Eliseev V. V., Grishko E. A., Samochernykh K. A. Short-term and long-term results of surgical treatment of ruptured tiny cerebral aneurysms: predictors of adverse outcomes. Russian Neurosurgical Journal named after Professor A. L. Polenov. 2024;XVI(1):32–43. (In Russ.). Doi: 10.56618/2071-2693_2024_16_1_32.

4. Mahlamaki K., Rautalin I., Korja M. Case fatality rates of subarachnoid hemorrhage are decreasing with substantial between-country variation : a systematic review of population-based studies between 1980 and 2020. Neuroepidemiology. 2022;6(6):402–412. Doi: 10.1159/000526983.

5. Treggiari M. M., Rabinstein A. A., Busl K. M. et al. Guidelines for the neurocritical care management of aneurysmal subarachnoid hemorrhage. Neurocrit. Care. 2023;39(1):1–28. Doi: 10.1007/s12028-023-01713-5.

6. Konovalov A. N., Krylov V. V., Filatov Yu. M., Eliava Sh. Sh., Tkachev V. V., Parfenov V. E., Svistov D. V., Antonov G. I., Lazarev V. A., Ivanova N. E., Piradov M. A., Lapatukhin V. G., Skorokhod A. A., Kurdyumova N. V., Lubnin A. Yu., Tseytlin A. M. Clinical recommendations for the treatment of patients with subarachnoid hemorrhage due to rupture of cerebral aneurysms. 2012, pp. 1–24. (In Russ.)

7. Hoh B. L., Ko N. U., Amin-Hanjani S. et al. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline From the American Heart Association/American Stroke Association. Stroke. 2023;54(7):e314–e370. Doi: 10.1161/STR.0000000000000436.

8. Lu X., Ji C., Wu J. et al. Intrathecal Fibrinolysis for Aneurysmal Subarachnoid Hemorrhage: Evidence From Randomized Controlled Trials and Cohort Studies. Front. Neurol. 2019;(10):885. Doi: 10.3389/fneur.2019.00885.

9. Dilmen Ö. K., Bonhomme V. Management of Aneurysmal Subarachnoid Haemorrhage and its Complications : A Clinical Guide. Turk J Anaesthesiol Reanim. 2023;51(3):170–178. Doi: 10.4274/TJAR.2023.231205.

10. Findlay J. M. Current Management of Aneurysmal Subarachnoid Hemorrhage. Neurol. Int. 2025;17(3):36. Doi: 10.3390/neurolint17030036.

11. Vergouwen M. D. I., Rinkel G. J. E. Emergency Medical Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care. 2023;(39):51–58. Doi: 10.1007/s12028-023-01757-7.

12. Thilak S., Brown P., Whitehouse T. et al. Diagnosis and management of subarachnoid haemorrhage. Nat Commun. 2024;(15):1850. Doi: 10.1038/s41467-024-46015-2.

13. Lauzier D. C., Jayaraman K., Yuan J. Y. et al. Early brain injury after subarachnoid hemorrhage: incidence and mechanisms. Stroke. 2023;(54): 1426–1440. Doi: 10.1161/STROKEAHA.122.040072.

14. Lens C., Coeckelberghs E., Seys D. et al. Variation in stroke care at the hospital level: A cross-sectional multicenter study. Front Neurol. 2022;(13): 1004901. Doi: 10.3389/fneur.2022.1004901.

15. Zhou X., Bates A. H., Mahajan U. V. et al. Racial differences in time to blood pressure control of aneurysmal subarachnoid hemorrhage patients: A single-institution study. PLoS One. 2023;(18):e0279769. Doi: 10.1371/journal.pone.0279769.

16. Elbir Ç., Ülkü G., Dolgun H. et al. Aneurysmal Subarachnoid Hemorrhage; Early Surgery; Neurosurgeons Experience; Patient Outcome. World Neurosurgery. 2025;(194):123509. Doi: 10.1016/j.wneu.2024.11.092.

17. Mikeladze K. G., Okishev D. N., Belousova O. B., Konovalov An. N., Pilipenko Iu. V., Kheĭreddin A. S., Ageev I. S., Shekhtman O. D., Kurdyumova N. V., Tabasaranskiĭ T. F., Okisheva E. A., Éliava Sh. Sh., Yakovlev S. B. Intra-arterial administration of verapamil for prevention and treatment of cerebral angiospasm after SAH due to cerebral aneurysm rupture. Burdenko’s Journal of Neurosurgery. 2018;82(4):23–31. (In Russ.) Doi: 10.17116/neiro2018824236.

18. Zhu W., Ling X., Petersen J. D. et al. Clipping versus coiling for aneurysmal subarachnoid hemorrhage : a systematic review and metaanalysis of prospective studies. Neurosurgical Review. 2022;45(2):1291–1302. Doi: 10.1007/s10143-021-01704-0.

19. Gadzhiagaev V. S., Shekhtman O. D., Konovalov A. N. et al. Surgical treatment of large and giant ACA aneurysms in endovascular era: analysis of large clinical series. World Neurosurgery. 2022;165:e298–e310. Doi: 10.1016/j.wneu.2022.06.036.

20. Pilipenko Y. V., Eliava S. S., Konovalov A. N., Grebenev F. V., Barchunov B. V. The results of surgery for giant aneurysms of the middle cerebral arteries : a retrospective stud. Almanac of Clinical Medicine. 2023;51(1):32–44. (In Russ.) Doi: 10.18786/2072-0505-2023-51-005.

21. Samuels O. B., Sadan O., Feng C. et al. Aneurysmal Subarachnoid Hemorrhage: Trends, Outcomes, and Predictions from a 15-Year Perspective of a Single Neurocritical Care Unit. Neurosurgery. 2021;88(3):574–583. Doi: 10.1093/neuros/nyaa465.

22. Shetova I. M., Shtadler V. D., Matveev P. D., Lukyanchikov V. A., Krylov V. V. Surgical Treatment of Cerebral Aneurysms in the Acute Period of Subarachnoid Hemorrhage: Long-Term Result. Emergency Medical Care : Russian Sklifosovsky Journal. 2021;10(2):328–336. (In Russ.) Doi: 10.23934/2223-9022-2021-10-2-328-336.

23. Lukyanchikov V. A., Shetova I. M., Shtadler V. D., Kudryashova N. E., Guseynova G. K., Kiseleva А. A., Krylov V. V. Results of revascularizing operations performed in the acute period of subarachnoid hemorrhage. Russian journal of neurosurgery. 2021;23(2):14–24. (In Russ.) Doi: 10.17650/1683-3295-2021-23-2-14-24.