Laryngeal edema requiring reintubation during clazosentan therapy for aneurysmal subarachnoid hemorrhage: A case report

Abstract

Cerebral vasospasm associated with aneurysmal subarachnoid hemorrhage (aSAH) is strongly linked to poor neurological outcomes, making its prevention critically important. Clazosentan, a selective endothelin A (ET_A) receptor antagonist, has shown promise in preventing cerebral vasospasm; however, fluid retention and other edema-related complications remain significant concerns. We report a case of a 74-year-old woman with aSAH who developed rapid-onset laryngeal edema immediately after extubation during clazosentan administration, requiring emergent reintubation. In this case, several contributing factors were considered, including relatively enhanced endothelin B (ET_B) receptor signaling due to ET_A blockade, systemic inflammation following SAH, and age-related endothelial fragility. These factors likely led to abnormal vascular hyperpermeability and localized mucosal edema. Anatomically, the larynx is predisposed to pronounced edema even with minimal vascular leakage, and mechanical stimulation during extubation may have triggered the acute airway obstruction. This case serves as a critical warning regarding the potential risk of upper airway edema during clazosentan therapy and highlights the necessity of thorough airway evaluation and heightened vigilance during extubation in patients receiving this medication.