A Remarkable Recovery from Debilitating Aneurysm Rupture: A Case Report

Case Diagnosis: Subarachnoid hemorrhage (SAH) from left ICA aneurysm

Case Description or Program Description: 22-year-old female with depression and ADHD presented after falling off an exercise machine. Head CT showed SAH with extension into 3rd, 4th and lateral ventricles. Modified Fisher 4, Hunt-Hess 3. Cerebral angiogram showed left ICA segment suspicious for blister aneurysm, confirmed on MRA. Patient underwent right ICA flow-diverting stent, external ventricular drainage (EVD) placement, and right PCA aneurysm coiling. Hospital course complicated by intracranial pressure (ICP) crises, vasospasm, respiratory failure requiring tracheostomy, intention tremors, and opioid withdrawal symptoms after a fentanyl drip.

Setting: Urban academic inpatient rehabilitation facility

Assessment/Results: Patient arrived to acute rehab 6 weeks after initial presentation with significant medication burden including fentanyl patch, propranolol, and multiple psychiatric medications, notably haloperidol. On admission, functional status was ModA using walker to ambulate given ataxic and unsteady gait. She was limited by severe intention tremors that interfered with feeding and dressing. Given concern for extrapyramidal symptoms, lurasidone and haloperidol were discontinued with resolution in tremors, allowing discontinuation of propranolol. Fentanyl patch was tapered off and patient was de-cannulated. Patient made remarkable recovery over 2 weeks and was discharged with a functional status of independent in ADLs and ambulating community distances independently with no assistive device.

Discussion (relevance): Spontaneous SAH is associated with significant functional impairment, with only 60% of survivors being functionally independent after one year. Acute rehabilitation has potential to rapidly improve function in a young patient with aneurysmal SAH. Despite the severity of initial imaging, ICP crises, vasospasm, and respiratory failure, she was still able to return to independent function on discharge.

Conclusions: This case highlights the role of rehab in helping a young patient with severe SAH and multiple medical complications leave the hospital at an independent level. Key components of her improvement involved weaning off several psychiatric medications and opioids, and early tracheostomy decannulation.