Abstract

Background: We report the first case of extracranial-intracranial (EC-IC) cerebral bypass in a postpartum woman with a ruptured cerebral aneurysm unsuitable for endovascular treatment. We also review literature on aneurysmal subarachnoid hemorrhage (aSAH) in pregnancy, including delivery timing, treatment strategies,bypass techniques, and anesthetic management.

Case Report: A 33-year-old woman at 35 weeks of pregnancy presented with seizures and coma (GCS 3/15). She was intubated and transferred to hospital. CT revealed a Fisher IV subarachnoid hemorrhage due to a ruptured 21 mm left Sylvian aneurysm, with cerebral herniation.
An emergency C-section was performed, followed by external ventricular drainage. The cerebral aneurysm was not suitable for endovascular treatment. She underwent a temporo-sylvian artery bypass, allowing for aneurysm clipping. Unless intensive reanimation supports implemented, progressive multi-organ failure included refractory lactic acidosis, renal failure and liver dysfunction. Family opted for comfort measures after consensus.

Discussion: Managing ruptured cerebral aneurysms in pregnancy requires a multidisciplinary approach due to maternal-fetal considerations. We review the epidemiology of pregnancy-related aneurysms and discussadherence to current treatment guidelines. Endovascular and surgical options are compared, with emphasis on delivery timing and intervention choice. In this case report, bypass techniques are discussed, highlighting the role of direct revascularization when aneurysms are unclippable or uncoilable. Anesthetic management is also addressed, given its critical impact on outcomes.

Conclusion: Ruptured cerebral aneurysms in pregnant women are rare and complex. In select cases, cerebral bypass followed by clipping may be a viable option when endovascular treatment is not possible. Larger studies are needed to assess the safety and efficacy of these approaches.