Whole-brain CT Perfusion at Admission and During Delayed Time-window Detects the Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage

Objective To evaluate the utility of computed tomography perfusion(CTP)both at admission and during delayed cerebral ischemia time-window(DCITW)in the detection of delayed cerebral ischemia(DCI)and the change in CTP parameters from admission to DCITW following aneurysmal subarachnoid hemorrhage.Methods Eighty patients underwent CTP at admission and during DCITW.The mean and extreme values of all CTP parameters at admission and during DCITW were compared between the DCI group and non-DCI group,and comparisons were also made between admission and DCITW within each group.The qualitative color-coded perfusion maps were recorded.Finally,the relationship between CTP parameters and DCI was assessed by receiver operating characteristic(ROC)analyses.Results With the exception of cerebral blood volume(P=0.295,admission;P=0.682,DCITW),there were significant differences in the mean quantitative CTP parameters between DCI and non-DCI patients both at admission and during DCITW.In the DCI group,the extreme parameters were significantly different between admission and DCITW.The DCI group also showed a deteriorative trend in the qualitative color-coded perfusion maps.For the detection of DCI,mean transit time to the center of the impulse response function(Tmax)at admission and mean time to start(TTS)during DCITW had the largest area under curve(AUC),0.698 and 0.789,respectively.Conclusion Whole-brain CTP can predict the occurrence of DCI at admission and diagnose DCI during DCITW.The extreme quantitative parameters and qualitative color-coded perfusion maps can better reflect the perfusion changes of patients with DCI from admission to DCITW.

A prospective cohort study on serum A20 as a prognostic biomarker of aneurysmal subarachnoid hemorrhage

BACKGROUND:A20 may be a neuroprotective factor.Herein,we aimed to investigate whether serum A20 levels were associated with disease severity,delayed cerebral ischemia(DCI),and outcome after aneurysmal subarachnoid hemorrhage(aSAH).METHODS:In this prospective cohort study containing 112 aSAH patients and 112 controls,serum A20 levels were quantified.At 90 d poststroke,Modified Rankin Scale(MRS) scores≥3 were defined as a poor outcome.All correlations and associations were assessed using multivariate analysis.RESULTS:Compared with controls,there was a significant elevation of serum A20 levels in patients(median 123.7 pg/mL vs.25.8 pg/mL;P<0.001).Serum A20 levels were independently correlated with Hunt-Hess scores(β 9.854;95% confidence interval [95% CI] 2.481-17.227,P=0.009) and modified Fisher scores(β 10.349,95% CI 1.273-19.424,P=0.026).Independent associations were found between serum A20 levels and poor outcome(odds ratio [OR] 1.015,95%CI 1.000-1.031,P=0.047) and DCI(OR 1.018,95% CI 1.001-1.035,P=0.042).Areas under the curve for predicting poor outcome and DCI were 0.771(95% CI 0.682-0.845) and 0.777(95% CI 0.688-0.850),respectively.Serum A20 levels ≥128.15 pg/mL predicted poor outcome,with a sensitivity of 73.9% and specificity of 74.2%,and A20 levels ≥160.55 pg/mL distinguished the risk of DCI with65.5% sensitivity and 89.2% specificity.Its ability to predict poor outcome and DCI was similar to those of Hunt-Hess scores and modified Fisher scores(both P>0.05).CONCLUSION:Enhanced serum A20 levels are significantly associated with stroke severity and poor clinical outcome after aSAH,implying that serum A20 may be a potential prognostic biomarker for aSAH.

D-dimer may predict poor outcomes in patients with aneurysmal subarachnoid hemorrhage: a retrospective study

Serum biomarkers may play a reliable role in predicting the outcomes of patients with aneurysmal subarachnoid hemorrhage. This study retrospectively analyzed the relationship between serum biomarkers on admission and outcomes in patients with aneurysmal subarachnoid hemorrhage. We recruited 146 patients with aneurysmal subarachnoid hemorrhage who were treated in Renmin Hospital of Wuhan University of China between 1 May 2014 and 30 March 2016. There were 57 males and 89 females included and average age of included patients was 57.03 years old. Serum samples were taken immediately on admission（within 48 hours after initial hemorrhage） and the levels of serum biomarkers were detected. Baseline information, complications, and outcomes at 6 months were recorded. Univariate and multivariate logistic regression analyses were used to explore the relationship between biomarkers and clinical outcomes. Receiver operating characteristic curves were obtained to investigate the possibility of the biomarkers predicting prognosis. Of the 146 patients, 102 patients achieved good outcomes and 44 patients had poor outcomes. Univariate and multivariate analyses showed that high World Federation of Neurosurgical Societies grade, high serum D-dimer levels, and high neurological complications were significantly associated with poor outcomes. Receiver operating characteristic curves verified that D-dimer levels were associated with poor outcomes. D-dimer levels strongly correlated with neurological complications. In conclusion, we suggest that D-dimer levels are a good independent prognostic factor for poor outcomes in patients with aneurysmal subarachnoid hemorrhage.

Serial lumbar puncture reduces cerebrospinal fluid (CSF) infection during removal of hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling

The present study aimed to compare the complications and clinical outcomes of serial lumbar puncture（LP） and lumbar cerebrospinal fluid（CSF） drainage（LD） of patients with aneurysmal subarachnoid hemorrhage and provide more evidence to guide clinical management.In this retrospective study,41 and 39 aneurysmal subarachnoid hemorrhage patients were enrolled in the LP and LD group,respectively.Clinical outcomes,including CSF infection,intracerebral hemorrhage,vasospasm,hydrocephalus,death,length of stay,duration of drainage and the Glasgow Outcome Scale score were compared between the two groups.By comparing with the LP group,the LD group showed a significantly higher rate of CSF infection（P= 0.029） and shorter duration of drainage（P〈 0.001）.Both groups displayed similar rates of vasospasm,hydrocephalus,intracerebral hemorrhage,the Glasgow Outcome Scale score one month after endovascular coiling and length of stay（P〉 0.05,respectively）.In conclusion,both LD and serial LP are effective methods in the treatment of aneurysmal subarachnoid hemorrhage; besides,serial LP can reduce the incidence of CSF infection in draining hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling.

Serum Gamma-glutamyl Transferase Levels Predict Functional Outcomes after Aneurysmal Subarachnoid Hemorrhage

Objective We aim to explore the potential association between serum gamma-glutamyl transferase levels and functional outcome after aneurysmal subarachnoid hemorrhage in a Chinese population. Methods A total of 386 aneurysmal subarachnoid hemorrhage patients were included in the study from September 2007 to February 2015. Baseline serum gamma-glutamyl transferase levels and 6-month follow-up functional outcomes were determined. A poor outcome was defined as a modified ranking scale score of ≥ 3. The multivariable logistic model was used to analyze the relationship between serum gamma-glutamyl transferase and clinical outcomes after aneurysmal subarachnoid hemorrhage. Results The adjusted poor outcome rates of patients with gamma-glutamyl transferase levels of 〈 30 U/L, 30-50 U/L and ≥ 50 U/L were 16.7%, 19.6%, and 34.4%, respectively （P 〈 0.01）. The age-sex and multivariable adjusted odds ratios （95% confidence intervals） of poor prognosis comparing the top group （≥ 50 U/L） with the lowest group （〈 30 U/L） were 5.76 （2.74-12.13）, 6.64 （2.05-21.52）, and 6.36 （1.92-21.02）. A significant linear trend existed between gamma-glutamyl transferase level and aneurysmal subarachnoid hemorrhage prognosis. This association was also observed among nondrinkers. Conclusion Patients with higher gamma-glutamyl transferase levels were more likely to have a poor prognosis. Serum gamma-glutamyl transferase can be considered to be an independent predictor of functional outcomes after aneurysmal subarachnoid hemorrhage.

Tenascin-C in aneurysmal subarachnoid hemorrhage: deleterious or protective?

Subarachnoid hemorrhage（SAH）caused by the rupture of a cerebral aneurysm is a well-known devastating cerebrovascular disease.Post-SAH brain is vulnerable,associated with early brain injury（EBI;Suzuki,2015）.

Effectiveness and Influencing Factors of Comprehensive Rehabilitation Therapy in Patients with Aneurysmal Subarachnoid Hemorrhage

This study aimed to determine the effectiveness of comprehensive rehabilitation for patients with aneurysmal subarachnoid hemorrhage (aSAH) and to explore the factors influencing the prognosis of rehabilitation. This was a retrospective study. Twenty-five patients with aSAH were treated with physical therapy, occupational therapy, speech therapy, cognitive therapy, music therapy, Chinese acupuncture, hyperbaric oxygen, and transcranial magnetic stimulation. The general data of all patients were collected, and the functional scores at admission were compared with those at discharge. The Mini Mental State Examination, Fugl-Meyer Assessment Scale (FMAS) for motor and balance assessment, Holden Functional Ambulation Classification (FAC), modified Rankin Scale, National Institute of Health Stroke Scale, Modified Barthel Index for activities of daily living (ADL), and Glasgow Outcome Scale were significantly improved among 25 patients with aSAH after 1 month of comprehensive rehabilitation training. Hydrocephalus was an independent factor of the ability to perform ADLs (odds ratio, 0.29;95% confidence interval, 2.03. 3.15;p = 0.000). The improvement of ADLs in aSAH patients was not related to sex, surgical method, aneurysm location, age, or smoking status. Comprehensive and professional rehabilitation is effective for the cognition, movement, walking, ADLs, and functional prognosis of patients with aSAH, while early hydrocephalus may be a risk factor for poor ADLs.

Safety and feasibility of ultra-early lumbar puncture in patients with aneurysmal subarachnoid hemorrhage

Objective:to evaluate the clinical efficacy and safety of ultra-early lumbar puncture drainage of cerebrospinal fluid(CSF)in patients with aneurysmal subarachnoid hemorrhage(SAH).Methods:patients(n=140)with aneurysmal SAH were randomly divided into observation group(n=70)and control group(n=70).After admission,CSF was drained by ultra-early lumbar puncture in the observation group and intermittent lumbar puncture after aneurysm operation in the control group.The incidences of early aneurysm rupture,acute hydrocephalus and delayed hydrocephalus were compared between the two groups.Results:there was no significant diflerence in the incidence of early-ruptured aneurysm and acute hydrocephalus between the two groups,but the incidence of delayed hydrocephalus in the observation group was significantly lower than that in the control group.Conclusion:ultra-early lumbar puncture drainage of CSF in anexirysmal SAH can effectively reduce the incidence of long-term delayed hydrocephalus and it is a safe and effective treatment.

Hyperacute cEEG Attenuation in Aneurysmal Subarachnoid Hemorrhage

We describe hyperacute generalized EEG slowing and then attenuation captured at the moment of subarachnoid hemorrhage in a monitored patient. This is the first reported cEEG capture of aneurysmal subarachnoid hemorrhage in the literature.

The clinical study of preoperative external lumbar drainage in patients with aneurysmal subarachnoid hemorrhage in Hunt and Hess grades Ⅰ～Ⅲ undergoing early surgery

Objective To explore the therapeutic effect of preoperative external lumbar drainage in Hunt and Hess grade Ⅰ～Ⅲ patients with subarachnoid hemorrhage (SAH) undergoing early surgery for intracranial aneurysms. Methods 101 cases of gradeⅠ～Ⅲ patients according to the classification of Hunt and Hess

The “Brain Stress Timing” phenomenon and other misinterpretations of randomized clinical trial on aneurysmal subarachnoid hemorrhage

Clipping and coiling are currently the two alternatives in treatment of ruptured cerebral aneurysms. In spite of some meritorious analysis, further discussion is helpful to understand the actual state of art. Retreatment and rebleeding rates clearly favors clipping, although short-term functional outcome seems to be beneficial for clipping, while this different is not such if we perform the comparison at a longer follow up. Longterm follow ups and cost analysis are mandatory to have a clear view of the current picture in treatment of subarachnoid hemorrhage. Treatment strategy should be made by a multi-disciplinary team in accredited centers with proficient experience in both techniques.

Clinical characteristics of asymptomatic Terson syndrome in the patients with aneurysmal subarachnoid hemorrhage

●AIM:To investigate clinical characteristics of asymptomatic Terson syndrome and its clinical impact in patients with aneurysmal subarachnoid hemorrhage(SAH).●METHODS:This retrospective,interventional study included 31 patients with aneurysmal SAH,and the medical records were reviewed.In addition to baseline characteristics of the study population such as age,sex,and underlying medical history,multi-modal imaging analysis,including fluorescein angiography(FA),spectral domain optical coherence tomography(SD-OCT),were also reviewed.Glasgow Coma Scale(GCS),Hunt-Hess(HH)grade,and Fisher scale at the time of admission,and functional outcome by using modified Rankin Scale(mRS)at 6 mo were compared.●RESULTS:Of the 31 patients,10 patients(32.3%)were diagnosed with Terson syndrome.All the patients with Terson syndrome did not report visual symptoms at the time of ophthalmologic screening.FA showed microvascular changes of retinal capillaries and varying degrees of disc leakage.SD-OCT allowed intuitive anatomical localization of multi-layered retinal hemorrhages and assessment of ellipsoid zone integrity.The patients with Terson syndrome showed significantly worse GCS(P=0.047)and HH grade(P=0.025)than those without,except Ficher scale(P=0.385).There was no significant difference in the mRS(P=0.250)at 6 mo.Among baseline factors,the HH grade was the only significant factor associated with Terson syndrome(B=1.079,P=0.016).●CONCLUSION:In our study,32.3%of the patients have Terson syndrome without visual symptoms.The baseline HH grade is significantly correlated with Terson syndrome,and there is no significant difference in the functional outcome between the patients with and without Terson syndrome.Terson syndrome may develop without any visual symptoms as shown in our study,and ophthalmologic screening may be recommended to prevent further visual deterioration especially in the patients with poor HH grade at the time of aneurysmal SAH.

Toll-like receptor 4 as a possible therapeutic target for delayed brain injuries after aneurysmal subarachnoid hemorrhage

Neuroinflammation is a well-recognized consequence of subarachnoid hemorrhage（SAH）, and Toll-like receptor（TLR） 4 may be an important therapeutic target for post-SAH neuroinflammation. Of the TLR family members, TLR4 is expressed in various cell types in the central nervous system, and is unique in that it can signal through both the myeloid differentiation primary-response protein 88-dependent and the toll receptor associated activator of interferon-dependent cascades to coordinate the maximal inflammatory response. TLR4 can be activated by many endogenous ligands having damage-associated molecular patterns including heme and fibrinogen at the rupture of an intracranial aneurysm, and the resultant inflammatory reaction and thereby tissue damages may furthermore activate TLR4. It is widely accepted that the excreted products of TLR4 signaling alter neuronal functions. Previous studies have focused on the pathway through nuclear factor（NF）-κΒ signaling among TLR4 signaling pathways as to the development of early brain injury（EBI） such as neuronal apoptosis and blood-brain barrier disruption, and cerebral vasospasm. However, many findings suggest that both pathways via NF-κΒ and mitogen-activated protein kinases may be involved in EBI and cerebral vasospasm development. To overcome EBI and cerebral vasospasm is important to improve outcomes after SAH, because both EBI and vasopasm are responsible for delayed brain injuries or delayed cerebral ischemia, the most important preventable cause of poor outcomes after SAH. Increasing evidence has shown that TLR4 signaling plays an important role in SAH-induced brain injuries. Better understanding of the roles of TLR4 signaling in SAH will facilitate development of new treatments.

Post-Aneurysmal Subarachnoid Hemorrhage Vasospasm, Clinical Correlation between the Aneurysm Site and Clinical Vasospasm

Background: Intracranial vasospasm is a common complication following subarachnoid hemorrhage (SAH). The radiographic vasospasm can reach up to 90% of aneurysmal SAH. Materials and Methods: 139 consecutive patients admitted to Cairo University Hospitals from June 2013 to September 2014 with SAH who had been enrolled in a retrospective controlled study were analyzed retrospectively for the occurrence of vasospasm. The data collected from the charts of Cairo University Hospitals were the patient’s demographics, clinical presentation, aneurysm location, treatment modality, and Glasgow Outcome Scale (GOS) scores. We excluded 24 patients with nonaneurysmal SAH, 3 internal carotid artery (ICA) aneurysms, 7 with multiple aneurysms and 4 patients died before treatment. Results: 72 males and 29 females were included in the study, mean age 53.5 ± 11.5 years. Twelve patients had aneurysms located in the vertebral artery group, 24 had middle cerebral artery aneurysms, 11 had pericallosal aneurysms, and 54 patients had anterior communicating artery (ACoA) complex aneurysms. Radiographic vasospasm occurred in 62.4% with the highest incidence (75.9%) at the ACoA complex group. Symptomatic vasospasm occurred in 48.5% with the highest incidence (63%) at the anterior communicating artery complex aneurysm location. The mean GOS at 6 months follow-up was 4.2. The worse GOS was found in the vertebral artery (VA) aneurysm group with a mean of 3.75. Conclusion: Aneurysms of the anterior communicating artery complex group have a greater risk of both radiographic and clinical vasospasm. Also, the worse 6 months follow-up GOS when an aneurysm was located in the VA group.

Can admission lipoprotein-associated phospholipase A2 predict the symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage?

Background:Inflammation has been believed to be related to the development of cerebral vasospasm following aneurysmal subarachnoid hemorrhage(aSAH).A potential biomarker for vascular inflammation that is well recognized is the lipoprotein-associated phospholipase A2(Lp-PLA2).However,whether Lp-PLA2 can predict the occurrence of symptomatic cerebral vasospasm(SCV)in aSAH patients is still unknown.Thus,this study aimed to assess the value of Lp-PLA2 for predicting SCV in patients with aSAH.Methods:Between March 2017 and April 2018,we evaluated 128 consecutive aSAH patients who were admitted in the First Affiliated Hospital of Fujian Medical University.Their Lp-PLA2 level was obtained within 24 h of the initial bleeding.Factors might be related to SCV were analyzed.Results:Compared to patients without SCV,those with SCV(9.4%,12/128)had significantly higher Lp-PLA2 level.Multivariate logistic analysis revealed that worse modified Fisher grade(OR=10.08,95%CI=2.04–49.86,P=0.005)and higher Lp-PLA2 level(OR=6.66,95%CI=1.33–3.30,P=0.021)were significantly associated with SCV,even after adjustment for confounders.Based on the best threshold,Lp-PLA2 had a sensitivity of 83.3%and a specificity of 51.7%for predicting SCV,as shown by the receiver operating characteristic curve analysis.In the poor World Federation of Neurosurgical Societies grade patient sub-group,patients with Lp-PLA2>200μg/L had significantly higher SCV rate than that of patients having Lp-PLA2≤200μg/L.Conclusion:The admission Lp-PLA2 level might be a helpful predictor for SCV in aSAH.

Neutrophil to lymphocyte ratio is a prognosis factor for post-operative pneumonia in aneurysmal subarachnoid hemorrhage patients

Background:Although a variety of risk factors of pneumonia after clipping or coiling of the aneurysm(post-operative pneumonia[POP])in patients with aneurysmal subarachnoid hemorrhage(aSAH)have been studied,the predictive model of POP after aSAH has still not been well established.Thus,the aim of this study was to assess the feasibility of using admission neutrophil to lymphocyte ratio(NLR)to predict the occurrence of POP in aSAH patients.Methods:We evaluated 711 aSAH patients who were enrolled in a prospective observational study and collected admission blood cell counts data.We analyzed available demographics and baseline variables for these patients and analyzed the correlation of these factors with POP using Cox regression.After screening out the prognosis-related factors,the predictive value of these factors for POP was further assessed.Results:POP occurred in 219 patients(30.4%)in this cohort.Patients with POP had significantly higher NLR than those without(14.11±8.90vs.8.80±5.82,P<0.001).Multivariate analysis revealed that NLR remained a significant factor independently associated with POP following aSAH after adjusting for possible confounding factors,including the age,World Federation of Neurosurgical Societies(WFNS)grade,endovascular treatment,and ventilator use.And the predictive value of NLR was significantly increased after WFNS grade was combined with NLR(NLRvs.WFNS grade×NLR,P=0.011).Conclusions:Regardless of good or poor WNFS grade,patients having NLR>10 had significantly worse POP survival rate than patients having NLR≤10.NLR at admission might be helpful as a predictor of POP in aSAH patients.

Risk factors of acute coagulation dysfunction after aneurysmal subarachnoid hemorrhage

Background: Although coagulopathy have been proved to be a contributor to a poor outcome of aneurysmal subarachnoid hemorrhage (aSAH), the risk factors for triggering coagulation abnormalities have not been studied after aneurysm clipping. Methods: We investigated risk factors of coagulopathy and analyzed the relationship between acute coagulopathy and outcome after aneurysm clipping. The clinical data of 137 patients with ruptured CA admitted to our institution was collected and retrospectively reviewed. Patient demographic data (age, sex), smoking, alcohol use, hypertension, diabetes, Hunt-Hess grade, Fisher grade, operation time, intraoperative total infusion volume, intraoperative blood loss, intraoperative transfusion, intraoperative hemostatic drug treatment, calcium reduction (preoperative free calcium concentration–postoperative free calcium concentration) were recorded. Coagulation was assessed within 24 h. Postoperative hemorrhage and infarction, deep venous thrombosis (DVT), and mortality were analyzed. Results: Coagulopathy was detected in a total of 51 cases (group I), while not in 86 cases (group II). Univariable analysis demonstrated that age, smoking, alcohol use, intraoperative total infusion volume, intraoperative blood loss, intraoperative transfusion, and calcium reduction (≥1.2 mg/dl) were related to coagulopathy. Non-conditional logistic regression analysis showed that age [OR, 1.037 (95% CI, 1.001–1.074);p=0.045] and calcium reduction (≥1.2 mg/dl) [OR, 5.509 (95% CI, 1.900–15.971);p=0.002] were considered as the risk factors for coagulopathy. Hunt-Hess grade [OR, 2.641 (95% CI, 1.079–6.331);p=0.033] and operation time [OR, 0.107 (95% CI, 1.012–0.928);p=0.043] were considered as the risk factors for hypocoagulopathy. There were 6 cases (11.7%) with cerebral infarction in group I, while 6 cases (6.98%) in group II (χ2=0.918, p=0.338). There were 4 cases (7.84%) with rebleeding in group I, while 5 cases (5.81%) in group II (χ2=0.215, p=0.643). The mortality was 9.80% (5/51) in group I, while 1.16% (1/86) in group II (χ2=5.708, p=0.017). DVT was not detected in all cases. Conclusions: In conclusion, age (≥65 years) and calcium reduction (≥1.2 mg/dl) were considered as the risk factors for coagulopathy and have been proved to be associated with higher mortality after aneurysm clipping.

Hydrocephalus after subarachnoid hemorrhage:A metaanalytic comparison of aneurysm treatments

AIM: To compare two treatments for ruptured cerebral aneurysm with reference to the relative risk of developing hydrocephalus.METHODS: We reviewed the English language literature on the risk of developing hydrocephalus after aneurysm treatment.Data were divided by type of study(randomized controlled trial,cohort trial,nonrandomized comparison,prospectively- and retrospectively-collected observational study).They were also divided by type of aneurysm treatment(microvascular- clipping,or endovascular- coiling).Additional predictive variables collected for each publication were average age,gender distribution,measures of hemorrhage volume and subarachnoid hemorrhage severity,aneurysm locations,time to treatment,duration of follow-up and date of publication.We employed meta-analysis to calculate pooled risk ratios of developing hydrocephalus in cases receiving aneurysm clipping vs those receiving coiling.Meta-regression was used to correct pooled results for covariates.RESULTS: Because indications for the two treatments are different,there is little clinical equipoise for treating most cases.The single randomized,controlled trial dealt with a small subset of ruptured aneurysms.Neither this nor pooled values from other studies which compared the two treatments had the power to demonstrate significant differences between the two treatments.Nor was there an apparent difference when observational data were meta-analytically pooled.However,when meta-regression was used to correct for predictive variables known to differ between the two treatment groups,a highly-significant difference appeared.Coiling is used more commonly in older,sicker patients with aneurysms in certain locations.These cases are more likely to develop hydrocephalus.When corrected for these covariates,the risk of hydrocephalus was found to be significantly lower in coiled vs clipped cases(P = 0.014).CONCLUSION: Pooled observational data were necessary to demonstrate that coiling ruptured cerebral aneurysms is associated with a lower risk of developing hydrocephalus than is clipping.

Rhino-orbito-cerebral mucormycosis complicated with an ophthalmic artery occlusion followed by subarachnoid hemorrhage

A 70-year-old female with poorly controlled diabetes developed sudden visual loss, ptosis and complete ophthalmoplegia of the right eye. Funduscopic examination showed the pale retina and the cherry red spot in the right eye. Fluorescein angiography and indocyanine green angiography demonstrated the absence of retinal arterial filling and choroidal perfusion in the right eye even 20 minutes after injecting the dye. The patient was diagnosed with right ophthalmic artery occlusion. Computed tomography (CT) showed diffuse mucosal thickening in the right ethmoidal sinus. Based on the clinical findings and endoscopic biopsy result, mucormycosis was confirmed. Amphotericin B (40 mg/day) and ceftriaxone (2 g/day) were intravenously administered. Despite the improvement of the right ethmoidal sinusitis and the right proptosis, the patient deteriorated into a comatose state after 19 days of systemic amphotericin B therapy. Although the previous CT showed no cerebral aneurysm, a repeated CT showed newly developed posterior communicating artery aneurysm and the subarachnoid hemorrhage. Despite the amphotericin B treatment and the improvement of the sinusitis, mucormycosis could cause sudden cerebral aneurysm rupture and subarachnoid hemorrhage resulting in coma.