Search Results (332)

Background: Chimeric antigen receptor T-cell (CAR-T) therapies have transformed the treatment of haematologic malignancies, yet their adverse event (AE) profiles across all approved agents have not been consolidated using a pharmacovigilance methodology in a single comparative analysis. Methods: Using the FDA Adverse Events Reporting System (FAERS) and OpenVigil 2.1, disproportionality analyses for all six FDA-approved CAR-T therapies were performed, stratified by target antigen: anti-CD19 agents (axicabtagene ciloleucel, tisagenlecleucel, lisocabtagene maraleucel, brexucabtagene autoleucel) and anti-BCMA agents (idecabtagene vicleucel, ciltacabtagene autoleucel). For each of the 25 most frequently reported AEs per agent, the report event counts, reporting odds ratio (ROR) with 95% confidence interval, proportional reporting ratio (PRR), and chi-squared statistic were calculated. Results: A total of 36,567 AEs were identified across all six agents. Cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome were the most frequent and most disproportionate AEs across all six therapies, with RORs exceeding 240 in every agent. Idecabtagene vicleucel had the highest ROR for cytokine release syndrome among all agents (ROR 1934.6), while brexucabtagene autoleucel had the highest ROR for immune effector cell-associated neurotoxicity syndrome (ROR 2089.6). Ciltacabtagene autoleucel exhibited a unique neurological toxicity profile, cranial nerve paralysis (ROR 3167.6, PRR 3055.0, chi² 199,190), parkinsonism (ROR 145.5, PRR 136.6, chi² 24,840), Bell’s palsy (ROR 380.4, PRR 370.3), and facial paralysis (ROR 72.7), consistent with the late neurotoxicity syndrome previously characterized, and absent from other agents’ top 25 AE lists. Brexucabtagene autoleucel demonstrated secondary malignancy signals including squamous cell carcinoma of skin (ROR 308.2) and myelodysplastic syndrome (ROR 97.9). Tisagenlecleucel showed the highest hypogammaglobulinemia signal among all agents (ROR 614.1, PRR 536.5, chi² 144,832) alongside a broad pancytopenia profile. Hemophagocytic lymphohistiocytosis was a significant finding with ciltacabtagene autoleucel (ROR 71.0) and brexucabtagene autoleucel (ROR 57.8). Conclusions: CAR-T therapies share class-wide toxicities in cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, but exhibit clinically important drug-specific and target-class-specific AE profiles. This consolidated FAERS-based analysis corroborates and extends prior pharmacovigilance work by providing direct cross-agent comparisons, and supports the use of agent-tailored monitoring strategies, particularly for the distinctive late neurological toxicity associated with ciltacabtagene autoleucel. Full article

B-cell maturation antigen (BCMA), G protein-coupled receptor class C group 5 member D (GPRC5D)-directed immunotherapies, chimeric antigen receptor T-cell (CAR-T) products, bispecific T-cell engagers (BsAbs), and antibody–drug conjugates (ADCs), have transformed the management of MM. Their adoption is now extending beyond tertiary centers following FDA modifications for CAR-T safety and the rapid uptake of off-the-shelf bispecifics suitable for community delivery. Clinicians outside specialist hubs must therefore be conversant with the full toxicity spectrum, including rare but high-consequence events, both for informed consent and for the work-up of post-therapy complications. In this narrative review, we report on the published literature around toxicities of approved and investigational BCMA- and GPRC5D-directed therapies, drawing on pivotal trial data, real-world cohorts, pharmacovigilance studies, and consensus management recommendations, with emphasis on practical recognition and risk mitigation. This review presents toxicities by a temporal pattern including acute (CRS, ICANS, infection, ocular, mucocutaneous), subacute (cranial nerve palsies, parkinsonism, myelitis, peripheral neuropathies IEC-associated enterocolitis and cardiovascular events), and long-term (prolonged cytopenias, second primary malignancies). We discuss validated risk stratification tools, such as the CAR-HEMATOTOX score, EASIX index, and multidisciplinary geriatric assessment, which predicts severe ICANS, infection, and resource utilization, supporting individualized pre-treatment planning. Safe delivery of immune therapies in community settings requires infrastructure for acute critical care, neurology, ophthalmology, infectious disease and long-term surveillance, but is achievable when paired with validated risk stratification and clear referral pathways. Full article

Although extensively studied in humans, data on the middle cranial fossa foramina remain limited in dogs, despite their different skull morphology and high relevance to veterinary neurology, surgery and oncology. In this retrospective anatomic study, we aimed to fill this gap by presenting the morphometric data of these foramina in domestic dogs of different breeds, ages, body weights, and skull sizes. The study used CBCT images of 40 dogs. Dogs were divided into three groups (small, medium, and large), regardless of sex, body weight, and breed, using neurocranium length. Then, morphological and morphometric analyses of the foramina were performed. The neurocranium length of each group differed significantly from the others (p < 0.001). In each group, the orbital fissure and round and oval foramina were bilaterally located rostrally to caudally and were of similar size (p > 0.05). While the orbital fissure was a canal in 80% of dogs, in dogs with medium and large skull sizes (17.5%), the spinous foramen showed variation, becoming both a foramen and a canal. The opening sizes increased along with the skull size (p < 0.001); the widest opening was the orbital fissure, and the narrowest opening (except for the spinous foramen) was the oval foramen. The findings may guide skull base surgeries, regional anesthesia, and the diagnosis of cranial nerve dysfunctions. Furthermore, a classification based on neurocranial length is anticipated to provide more objective craniometric measurements in animals with diverse head types and body weights. Full article

Background and Objectives: Percutaneous iliosacral screw fixation is a standard treatment for posterior pelvic ring instability and sacral insufficiency fractures. However, conventional transsacral S1 screw fixation is associated with notable complication rates, most commonly implant loosening; dysmorphic sacral anatomy increases the risk of iatrogenic L5 or S1 nerve root injury. This study presents a modified S1 trajectory to engage the high-density bone of the anterior and cranial S1 vertebral body (promontory) by transferring preoperative 3D planning to intraoperative 2D fluoroscopy. Materials and Methods: This retrospective study analyzed implant placements for posterior pelvic ring instability, including high-velocity trauma and fragility fractures of the pelvis (FFPs). Preoperative computed tomography (CT) multiplanar reconstruction defined a modified corridor from a posterior-caudal iliac entry point directed cranially and ventrally into the S1 promontory. The 3D trajectory was transferred intraoperatively using standard 2D fluoroscopy (lateral, anteroposterior, inlet, and outlet views) with the patient prone. In cases of reduced bone quality or intended sacroiliac fusion, 3D-printed titanium implants (triangular or cylindrical threaded, 10.0–13.5 mm outer diameter) were selected over 7.5 mm cannulated screws. Results: Overall, 137 implants were placed in 71 patients: 13 cannulated screws in high-velocity pelvic ring trauma, 72 triangular titanium sacroiliac fusion implants (iFuse Implant System^®, SI-Bone), and 52 threaded titanium fusion implants (iFuse TORQ^®, SI-Bone) in patients with FFP. The modified trajectory consistently engaged the anterior and cranial S1 vertebral body. Postoperative 3D CT confirmed accurate placement of all implants. No iatrogenic nerve injuries or revisions for implant malposition occurred. Mean follow-up was 12 ± 9 months. Conclusions: Preoperative 3D CT planning combined with standard 2D fluoroscopy guided a modified S1 trajectory toward the cranial S1 vertebral body. Accurate and safe implant placement was achieved in the prone position without navigation systems, providing a practical alternative when standard transverse trajectories are limited by narrow bony corridors or sacral or pelvic dysmorphy. Full article

Typhus (FBT), caused by Rickettsia typhi, rarely causes neurological disease. Herein, we describe neurological involvement in two cases of FBT. In the first case, an adult presented with persistent fever which deteriorated into status epilepticus. He was successfully treated with doxycycline and made a complete recovery. In the second case, a patient suffered an ischemic stroke and had a protracted clinical course but ultimately made a near complete recovery. In addition to these cases, we conducted a comprehensive narrative review of 43 cases of neurologic involvement in FBT reported from 1989 to 2025. Cases were excluded if there were pathologic discrepancies with typical cases of FBT. Presentations ranged from cranial nerve palsies to meningitis and fulminant encephalitis. This review highlights the spectrum of CNS complications associated with FBT and underscores the importance of early recognition and treatment with doxycycline to improve outcomes. Given the potential severity of neurologic involvement, clinicians in endemic areas should maintain a high index of suspicion for FBT in patients presenting with a febrile illness and neurologic symptoms. Full article

Background/Objectives: High common carotid artery bifurcation (CCAB) is an anatomic variant relevant to carotid endarterectomy that is associated with an increased risk of cranial nerve injury, particularly hypoglossal nerve injury. This study analyzed CCAB location relative to anterior neck landmarks as a method for categorizing its proximity to critical surgical structures. Methods: Eighty-one formalin-fixed donors were dissected, yielding 159 CCABs. CCAB height was classified relative to six transverse anterior neck planes using superficial anatomic landmarks. Distances from the CCAB to the hypoglossal nerve and angle of the mandible were measured. Superior thyroid (ST) artery origin was also recorded. Results: A majority of CCABs occurred near the hyoid bone, but locations varied between and within donors. CCAB height did not differ significantly by sex or by which side of the neck they were from. Higher CCABs were closer to the hypoglossal nerve and angle of the mandible. When using anterior neck landmarks, there was a strong linear relationship between the height of the CCAB and both the hypoglossal nerve and the angle of the mandible. The hypoglossal nerve looped inferior to the CCAB in 11 cases. ST artery origin varied, with higher CCABs originating from the common carotid artery more often. Conclusions: By using anterior neck landmarks to classify CCAB height, clinicians may establish a more precise definition of high CCAB that incorporates reliable estimates of hypoglossal nerve proximity. This approach may improve preoperative risk assessment, guide surgical selection, and reduce complications. Full article

Background: Neurovascular compression syndromes (NVCS) represent a spectrum of disabling neurologic disorders caused by vascular or structural compression of cranial nerves, most commonly at the root entry zone. Conditions such as trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GN) are associated with significant pain, functional impairment, and reduced quality of life. This review provides a multidisciplinary, anatomically grounded overview of the pathophysiology, diagnosis, imaging, and contemporary management strategies for NVCS. Methods: A narrative review of the literature was conducted, synthesizing historical perspectives, neuroanatomy of the cerebellopontine angle, mechanisms of neurovascular conflict, advances in imaging and neuromonitoring, and current treatment modalities. Medical, percutaneous, surgical, radiosurgical, and neuromodulatory approaches were evaluated, with emphasis on patient selection and outcome considerations. Results: Neurovascular compression, most frequently arterial compression at the root entry zone, leads to focal demyelination, ephaptic transmission, and neuronal hyperexcitability. High-resolution Magnetic resonance imagin (MRI) remains the diagnostic gold standard. First-line management for TN and related syndromes typically includes pharmacotherapy, particularly sodium channel blockers. Refractory cases may benefit from percutaneous rhizotomy, balloon compression, stereotactic radiosurgery, or microvascular decompression (MVD), which offers the most durable relief in appropriately selected patients. Emerging technologies, including endoscopic visualization, advanced neuromodulation, and virtual reality-assisted surgical planning, continue to refine treatment precision and safety. Conclusions: Effective management of NVCS requires a comprehensive understanding of neuroanatomy, pathogenesis, and individualized risk–benefit profiles. A multidisciplinary, stepwise approach optimizes outcomes and improves quality of life in patients with these complex disorders. Full article

Background/Objectives: Hypoglossal nerve palsy is a rare but disabling complication of general anesthesia, typically associated with tracheal intubation and head and neck surgery. This study evaluated the incidence, clinical characteristics, and potential mechanisms of postoperative tongue deviation after breast reconstruction and other surgeries performed under general anesthesia with orotracheal intubation. Methods: We retrospectively reviewed 240,646 consecutive general anesthetic procedures with orotracheal intubation performed at two tertiary hospitals between September 2011 and October 2025. Eighteen patients who developed new-onset postoperative tongue deviation were identified, and demographic features, surgical department, breast reconstruction status, anesthetic details, patient positioning, laterality of deviation, symptom duration, and recovery outcomes were analyzed. Results: Postoperative tongue deviation was documented in 18 patients, corresponding to an overall incidence of approximately 0.01%, most frequently after breast reconstruction (7/18, 38.9%), followed by vascular (27.8%), head and neck tumor (16.7%), neurosurgical (11.1%), and hepatobiliary–pancreatic surgery (5.6%). All seven breast-reconstruction cases occurred at the breast-cancer center hospital, corresponding to 0.31% of 2256 breast reconstructions. The median age was 58.0 years; 66.7% patients were female. Most patients (77.8%) achieved complete recovery, whereas 16.7% had residual deviation. Conclusions: Postoperative hypoglossal nerve palsy with tongue deviation is an exceptionally rare event after general anesthesia. In our two-center cohort, it was observed most frequently among patients undergoing breast reconstruction at one participating center; this pattern is confounded by institution-specific anesthetic and positioning practices and should not be interpreted as evidence that the procedure itself carries inherent risk. The findings are hypothesis-generating and suggest that prolonged operating time, repeated intraoperative position changes, and specific head-fixation and tube-fixation practices warrant prospective investigation. Meticulous head–neck alignment, careful tube fixation, and a structured postoperative cranial-nerve check (tongue-protrusion and voice-quality assessment in the recovery room and on postoperative day 1) may aid the early detection of this complication. Full article

General approaches of head and neck surgery involve varied procedures with developing perioperative care and a renewed effort on regional anaesthesia (RA) for intraoperative and postoperative analgesia. Due to the rich innervation and focus on enhanced recovery after surgery (ERAS), RA techniques, particularly ultrasound-guided ones, are becoming popular as part of an opioid-sparing multimodal analgesic regimen. However, the evidence base is heterogeneous and synthesised clinical guidance is needed. This narrative review, performed according to the Scale for the Assessment of Narrative Review Articles (SANRA) framework, summarises the existing literature on the role of RA in head and neck surgery, including anatomical basis, types of techniques used for RA, clinical applications, immediate outcomes and implementation. We conducted a comprehensive literature search, including studies published between January 2000 and October 2025 in English, across the PubMed/MEDLINE, Scopus, and Cochrane Library databases. Understanding of the anatomy of cervical plexus (C1–C4) and cranial nerves such as trigeminal V is basic to delineation of techniques into superficial (e.g., SCPB), deep and selective cranial nerve blocks. The evidence about decreases in postoperative pain intensity, opioid consumption (especially 24 h post-op) and decreased length of stay, largely through studies on thyroidectomy, has been consistent for SCPB as an adjunct to general anaesthesia. Ultrasound-guided regional anaesthesia (UGRA) has significantly enhanced precision and safety, reducing risks such as phrenic nerve paresis, although the concern for even higher complication rates remains with deeper or bilateral blocks. Although beneficial outcomes have been demonstrated, the literature is plagued by small and heterogeneous trials, variable block protocols, and a lack of data in complex oncologic resections or reconstructive settings. For successful implementation, there is a need for structured training programmes of anaesthesiologists and surgeons involved in the procedure performing UGRA together, institutional protocols on standardised technique, patient monitoring and outcomes auditing. RA is a useful and safe adjunct to head and neck surgery, providing analgesia in the short term and contributing to improved recovery during the perioperative period. Further studies should be conducted through large-scale, standardised trials to resolve the contributions of blocks in complex surgical cases and implement best practices for both training and clinical integration. Full article

Introduction. The superficial musculoaponeurotic system (SMAS) is fundamental for facial soft tissue support and surgical rejuvenation. Although its morphology in the midface and neck is well characterized, the structure of its cranial extension to the forehead remains a subject of terminological uncertainty. The aim of this study was to conduct a detailed histological and immunohistochemical examination of the forehead supporting structures to characterize their morphology and propose an expanded, region-specific classification of the SMAS. Material and methods. Full-thickness tissue specimens (n = 30) were obtained from five standardized facial regions (parotid, buccal, temporal, frontal, and cervical) from 12 male and 18 female body donors (aged 25–70 years). Specimens were processed for histological analysis using hematoxylin and eosin, van Gieson staining, and Masson’s trichrome. Immunohistochemical staining for S100 protein was used to identify neural structures. Morphometric analysis was performed on digitized sections to quantify interseptal distances and the depth of superficial nerve trunks. Results. The analysis confirmed the established SMAS types (I–V) in the cheek, parotid gland, and neck, confirming the validity of the method. Two distinct, sequentially arranged structures were identified on the forehead, proposed as new types. Type VI (neurovascular arborization) is a discrete fan-shaped structures with a central collagen core surrounding a neurovascular bundle, showing positive S100 staining. These structures, spaced approximately 2.2 mm apart, function as true retaining ligaments. Type VII (fibroseptal) SMAS patterns is vertically oriented, purely fibrous septa (retinacula cutis) connecting the aponeurosis to the dermis, devoid of neural elements, and spaced approximately 9.2 mm apart. Importantly, the superficial nerve trunks were located at an average depth of only 1.09 mm (range: 0.57–1.97 mm) from the skin surface. Conclusion. This study identified two novel SMAS patterns in the forehead—neurovascular arborization (type VI) and fibroseptal (type VII)—supporting the expanded functional seven-type classification of the SMAS. The extremely superficial location of the forehead nerves (average 1.1 mm) defines a critical “danger zone” for aesthetic procedures. These findings provide a refined anatomical basis for improving the precision and safety of both surgical and minimally invasive facial procedures. Full article

Background and Objectives: Chronic headache after craniotomy is common and may include neuropathic subtypes (scar neuroma pain, occipital neuralgia). However, no large series has quantified these phenotypes. We conducted a single-center retrospective review (n = 5624 adult craniotomy patients) to estimate the prevalence of post-craniotomy neuropathic pain and to describe its characteristics. Materials and Methods: Institutional records were screened to identify craniotomy patients referred to a multidisciplinary pain clinic (n = 272). Eligible cases were reviewed in tiers: (1) exclusion of primary headache and noncranial pain; (2) identification of “probable neuropathic cranial pain” based on documented neuropathic features (lancinating/scalp pain, trigger tenderness, dermatomal distribution); and (3) subgroup categorization into occipital neuralgia-like, supraorbital/supratrochlear neuralgia-like, and scar-site neuropathic pain phenotypes. The supraorbital/supratrochlear subgroup was defined by frontal or frontotemporal postoperative pain in the supraorbital region, local tenderness or Tinel-like hypersensitivity over the supraorbital/supratrochlear course, and/or response to supraorbital–supratrochlear nerve block. Data extracted included demographics, timing (surgery to pain referral), pain characteristics, and treatments (blocks, radiofrequency, medications). Results: Of 5624 craniotomy patients, 272 (4.8%) had pain clinic encounters. The initial review identified 124 cases with chronic post-craniotomy headache requiring follow-up; after detailed chart classification, probable neuropathic cranial pain was present in 111 cases (2% of the cohort). Among the 111 probable neuropathic cranial pain cases, the dominant regional phenotype was occipital neuralgia-like pain. In addition, eight patients (7.2%) demonstrated a supraorbital/supratrochlear neuralgia-like phenotype, predominantly after frontal or frontotemporal craniotomies. Scar-site neuropathic pain frequently coexisted with both regional phenotypes, supporting a partially overlapping spectrum rather than mutually exclusive categories. The median time from surgery to pain referral was several months (≈12–18 months). Management commonly included occipital nerve blocks (±steroid); some patients received pulsed radiofrequency ablation of the occipital nerves, and most were trialed on neuropathic analgesics (gabapentinoids, SNRIs, etc., according to neuropathic pain guidelines). Conclusions: A clinically meaningful subset of post-craniotomy patients develops chronic neuropathic cranial pain, most commonly with occipital, supraorbital/supratrochlear, or scar-related features. Because most postoperative headaches are managed through neurosurgical follow-up and improve without pain clinic referral, the present cohort likely underestimates the true burden of neuropathic post-craniotomy pain while enriching for its most refractory neuralgic presentations. This is nevertheless the subgroup that must be recognized, discussed with patients, studied prospectively, and targeted in future prevention strategies. Full article

Background/Objective: This study aimed to determine the prevalence of neurological symptoms and findings in patients with Ankylosing Spondylitis (AS) and to evaluate their relationship with disease activity. Methods: A total of 86 patients diagnosed with AS underwent a structured neurological examination including assessment of mental status, cranial nerves, motor system, deep tendon reflexes, pathological reflexes, and cerebellar/extrapyramidal functions. Sensory deficits and motor weakness were recorded. Orthostatic hypotension was evaluated as a clinical marker of autonomic involvement. Insomnia symptoms and neuropathic pain features were assessed clinically. Disease activity was quantified using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Associations between neurological findings, BASDAI scores, and inflammatory parameters were analyzed. Results: Motor weakness was observed in 5% of patients. Sensory deficits were present in 31% and orthostatic hypotension in 23% of patients. Insomnia symptoms were reported by 51% and neuropathic pain features by 53% of participants. A highly significant association was found between insomnia and neuropathic pain (p < 0.001). BASDAI scores were significantly higher in patients with insomnia, orthostatic hypotension, and sensory deficits (p = 0.004, p = 0.014, and p < 0.001, respectively). No significant association was observed between Anti-Tumor Necrosis Factor therapy and sensory deficits, and no significant correlation was demonstrated between neurological findings and C-reactive protein/Erythrocyte Sedimentation Rate values (p > 0.05). Conclusions: Neurological symptoms are common in AS and are associated with higher disease activity, without parallel changes in inflammatory markers such as CRP and ESR. Systematic evaluation of these symptoms may facilitate earlier identification of subgroups with a higher disease burden and inform individualized follow-up and management strategies. Full article

Background: Intracranial accessory nerve schwannomas involving the jugular foramen are rare tumors with heterogeneous clinical presentations. Although lower cranial nerve dysfunction is common, hypoglossal nerve palsy is uncommon and may obscure identification of the nerve of origin. Methods: A narrative review of the literature was conducted to identify reported cases from 1961 to December 2025. Clinical manifestations were categorized as initial and preoperative symptoms, and their temporal evolution was analyzed according to tumor location. Imaging findings, surgical management, and neurological outcomes were reviewed. An illustrative case with hypoglossal nerve palsy was included. Results: A total of 58 cases, including the present case, were identified. According to the Julow classification, 38 tumors were intracisternal and 20 were intrajugular. Intracisternal tumors predominantly caused posterior fossa compression symptoms, whereas intrajugular tumors more frequently showed lower cranial nerve dysfunction. Hypoglossal nerve palsy was observed in seven cases, including three as the initial symptom, and occurred mainly in intrajugular tumors. Imaging commonly demonstrated jugular foramen enlargement and, in selected cases, continuity with enlargement of the extracranial hypoglossal canal. Surgical treatment was associated with improvement or stabilization of hypoglossal nerve function in all reported cases. Conclusions: Accessory nerve schwannomas may occasionally present with hypoglossal nerve palsy, most likely due to secondary compression. Careful assessment of symptom progression and skull base imaging may improve preoperative diagnosis and surgical planning. Full article

Background and Clinical Significance: Neurosarcoidosis (NS) is a rare manifestation of systemic sarcoidosis involving the central nervous system, with highly variable neurological and endocrine presentations. Among these, anterior pituitary dysfunction is particularly uncommon and diagnostically challenging. Case Presentation: We report the case of a 37-year-old woman with a 4-year history of secondary amenorrhoea and an initially suspected pituitary microadenoma, who was ultimately diagnosed with probable NS presenting with multiaxial anterior pituitary insufficiency. Early magnetic resonance imaging (MRI) revealed a small pituitary lesion and isolated pituitary stalk thickening, without other central nervous system abnormalities. Subsequent imaging demonstrated contrast-enhancing lesions involving the meninges and cranial nerves, along with progression of pituitary stalk involvement and loss of the posterior pituitary bright spot. Further evaluation confirmed systemic sarcoidosis. High-dose corticosteroid therapy led to partial clinical and radiological improvement; however, relapse necessitated methotrexate, and persistent pituitary hormone deficiencies required long-term hormonal replacement. Conclusions: This case highlights the diagnostic complexity of NS presenting with isolated endocrine dysfunction and subtle imaging findings. It underscores the need to consider systemic sarcoidosis in patients with unexplained hypopituitarism. Full article

Background: Aneurysmal subarachnoid hemorrhage (SAH) during pregnancy is rare, occurring in approximately 0.01–0.05% of pregnancies, most commonly in the third trimester. Its management is particularly challenging, requiring careful consideration of both maternal and fetal outcomes. Methods: We report the case of a 32-year-old woman at 31 weeks of gestation who presented with severe headache and left third cranial nerve palsy. Imaging revealed diffuse SAH with significant obstructive hydrocephalus and a 5 mm left posterior communicating artery aneurysm. Following multidisciplinary discussion, surgical clipping was performed while preserving the pregnancy to allow for fetal lung maturation. On postoperative day 8, the patient developed right-sided weakness and aphasia secondary to severe vasospasm. Initial management with catecholamine-induced hypertension resulted in increased uterine contractions and fetal distress. Subsequent intra-arterial administration of nimodipine effectively resolved the vasospasm, enabling cessation of vasopressor therapy. After achieving fetal lung maturity, cesarean section was performed at 34 weeks, followed by ventriculo-peritoneal shunt placement for communicating hydrocephalus. Due to sustained shunt failure, the distal catheter was finally inserted into the superior vena cava at the junction of the atrium. Results: The patient showed gradual neurological recovery with complete resolution of third cranial nerve palsy, and both mother and infant were discharged without complications. Conclusions: This case highlights that while standard vasospasm therapies can be implemented during pregnancy, hemodynamic approaches may provoke maternal and fetal complications. Endovascular rescue strategies should be promptly considered for severe vasospasm, and ventriculo-atrial shunting for complex communicating hydrocephalus may serve as a viable alternative option in post-cesarean patients. Full article