ANEURYSMAL SUBARACHNOID HEMORRHAGE ASSOCIATED WITH NON-AUTOIMMUNE HEMOLYTIC ANEMIA IN A PATIENT WITH FIBROMUSCULAR DYSPLASIA: A CASE REPORT

Abstract

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) is a neurovascular emergency with high morbidity and mortality. Fibromuscular dysplasia (FMD), a noninflammatory and nonatherosclerotic arteriopathy, may predispose patients to the formation and rupture of intracranial aneurysms. Early microsurgical clipping of the ruptured aneurysm is an established strategy to prevent rebleeding; systemic postoperative complications, however, demand clinical surveillance and structured diagnostic reasoning. Objective: to report and discuss a case of non-autoimmune hemolytic anemia (NAIHA) in the postoperative period following clipping of a ruptured cerebral aneurysm in a patient with bilateral cervical fibromuscular dysplasia. Case report: a 52-year-old female smoker with hypertension presented with Fisher IV aSAH caused by "mirror" aneurysms of the internal carotid arteries and bilateral cervical FMD, and underwent microsurgical clipping. Three weeks after discharge, she developed severe hemolytic anemia (hemoglobin 3.1 g/dL) with reticulocytosis, elevated lactate dehydrogenase, indirect hyperbilirubinemia, undetectable haptoglobin and a negative direct antiglobulin test. After hemorrhagic, infectious, nutritional, drug-related, enzymatic and hemoglobinopathy causes were excluded, supportive treatment with packed red blood cell transfusion led to progressive clinical and laboratory recovery. Conclusion: a postoperative decrease in hemoglobin following clipping of a ruptured aneurysm, when accompanied by laboratory evidence of hemolysis and a negative direct antiglobulin test, should prompt a structured evaluation for NAIHA, avoiding automatic attribution to occult bleeding, and supports safer transfusion decisions.