Endovascular treatment for subarachnoid hemorrhage during pregnancy followed by minimum approaches for cerebral vasospasm

Background: Managing subarachnoid hemorrhage (SAH) during pregnancy is challenging due to its rarity, lack of definitive treatment guidelines, and significant concerns regarding both surgical and obstetric management for the pregnant mother and fetus. Treatment methods and medications must be carefully selected, considering the possibility of adverse effects and safety for both the pregnant mother and fetus. We present the case of a pregnant woman with SAH who underwent endovascular treatment (EVT) followed by minimum approaches for cerebral vasospasm prevention and treatment. Case Description: A 36-year-old female at 24 weeks of gestation presented with a headache without neurological deficits. Magnetic resonance imaging on admission showed SAH with diffuse clotting in the basal cistern. Digital subtraction angiography identified a small saccular aneurysm. We performed EVT, followed by minimum required prevention and treatment of cerebral vasospasm using fasudil hydrochloride, aspirin, and ozagrel sodium, as these agents seem to be associated with fewer adverse effects at 26 weeks of gestation. The patient exhibited a Glasgow outcome scale score of 5 at discharge, with no oral medications at 25 days after aneurysm rupture. The pregnancy progressed favorably, and a healthy infant was successfully delivered through a scheduled cesarean section in gestational week 37. The child showed no abnormalities at 1 year of age. Conclusion: We reported the case of a pregnant patient with SAH who underwent EVT, followed by the minimum required prevention and treatment for cerebral vasospasm. Clinicians should carefully select the medical approaches, including pharmacotherapies for both pregnant women with SAH and the fetus, considering radiation exposure and medication risks.