Subarachnoid haemorrhage and paraplegia in coarctation of aorta

Introduction: Subarachnoid haemorrhage (SAH) in patients with coarctation of aorta (CoA) is uncommon but well documented. Management in anaesthesia and in intensive care unit (ICU) must involve monitoring and management of perfusion in both pre-stenotic and post-stenotic circulation. We report a case of SAH in a patient with CoA who developed post-stenotic hypotension and its complication despite adequate pre-stenotic perfusion. Case Summary: A 41 year old hypertensive male was admitted with complaints of sudden headache, vomiting and palpitation of 1 day duration and blood pressure (BP) of 210/108 mmHg. Non-contrast computerised tomography head showed SAH. Cardiac evaluation showed complete stenosis of descending thoracic aorta just distal to the origin of left subclavian artery with post-stenotic refilling through intercostals. Anterior communicating artery aneurysm was seen on magnetic resonance (MR) angiography. Aneurysm was coiled through right carotid approach under general anaesthesia. Left radial artery was cannulated for invasive BP monitoring. Intraoperatively filling of the aneurysm and formation of thrombus was observed. Intra-arterial eptifibatide was administered and patient extubated keeping systolic BP 20% below baseline. He was maintained on same BP in ICU for next 48 hours. On third postoperative day the patient developed paraplegia and bowel distension. Urine output was normal. MR imaging revealed central intramedullary acute ischemic changes from conus medullaris upto D8 level. Conclusion: CoA is essentially two parallel circulations comprising of pre-stenotic and post-stenotic component. This case report underscores the importance of monitoring both components during management in anaesthesia and in ICU.