Intra-arterial fasudil infusion for symptomatic cerebral vasospasm following clipping of an unruptured middle cerebral artery aneurysm: A case report and literature review

We report the first known case of symptomatic unruptured intracranial aneurysm-associated cerebral vasospasm (UIA-CVS) following surgical clipping that was successfully treated with intra-arterial fasudil infusion. UIA-CVS is a rare postoperative complication for which no standardized treatment has been established. A 67-year-old woman with a 5-mm saccular aneurysm at the bifurcation of the left middle cerebral artery (MCA) underwent microsurgical clipping via a distal transsylvian approach. On postoperative day 7, she developed motor aphasia. Magnetic resonance angiography and digital subtraction angiography revealed significant vasospasm in the distal MCA territory. An intra-arterial infusion of fasudil hydrochloride 30 mg was administered over 2 consecutive days via a microcatheter. Rapid resolution of vasospasm and complete neurological recovery were achieved. At 5 years postoperatively, the patient has remained neurologically intact without recurrence. This case suggests that intra-arterial fasudil infusion may be a viable treatment for CVS even in the absence of subarachnoid hemorrhage, underscoring the importance of early recognition and timely intervention in postoperative vasospasm.