A Case That Encapsulates the Challenges of Practicing Vascular Neurosurgery in Iraq

Background: Despite the rich history of civilization and knowledge originating in Mesopotamia, encompassing modern-day Iraq, the recent history of the region has come to affect the provision of medical care there. We describe here a case of multiple intracranial aneurysms (MIA) that showcases the challenges of practicing vascular neurosurgery in Iraq. Issues regarding lack of resources, a strained healthcare infrastructure, paucity of orientation, and low patient socioeconomic status are discussed regarding their effect on prolonging the diagnosis and treatment of such complex and critical diseases.

Case Scenario: A 57-year-old woman with no past medical history on the record presented with sudden severe headache, photophobia, drowsiness, and meningismus in an ED in Babylon on December 31, 2021. A non-contrast CT scan was positive for a sellar hematoma indicating acute subarachnoid hemorrhage (SAH). The patient was admitted to the neurology ward for observation and symptomatic management, after which her relatives approached our team for a second opinion. Upon our request for a CT angiogram (CTA), we were informed that the current supervising team did not conduct the study, citing that it would be harmful to the patient within the first 15 days of a potential rupture aneurysm and would not provide clear results.

Following this, we recommended a CTA be conducted at a private facility. This was done on January 4, 2022, and the report concluded the absence of any stenosis, aneurysms, or arteriovenous malformations. Considering the yet unexplained SAH and clinical presentation of the patient, we arranged for her transfer to Baghdad, 140 miles from her location in Babylon. Upon arrival, a diagnostic catheter angiography was conducted on January 7, 2022, showing MIAs present in the right posterior communicating artery (PCoA), right superior hypophyseal artery (SHA), left posterior communicating artery, and right intraorbital ophthalmic artery.

A multitude of factors contributed to the decision to undergo open vascular surgery, including the lack of an endovascular service at our facility and the financial inability of the patient to undergo such a procedure. A right pterional approach was performed, and the right sylvian fissure was retracted to expose and dissect the supraclinoid internal carotid artery (ICA) and the right PCoA aneurysm. During the final inspection of the clipped aneurysm, we encountered intraoperative rupture of the SHA aneurysm. This was additionally clipped with no subsequent operative or post-operative complications. The left PCoA and right ophthalmic aneurysms were stable and asymptomatic at the 6-month follow-up.

Conclusion: This case exhibits various challenges facing vascular neurosurgeons in Iraq, where a patient suffering from MIA and acute SAH did not receive CTA or treatment until seven days post-presentation. The lack of resources and training and the prevalence of limited resources in the country lead to missed diagnoses and poor case management, often leading to increased morbidity and mortality. We hope that openly discussing these cases will bring attention to how medical provision can be improved for patients in Iraq.

Publication History

Article published online:
01 February 2023