Delayed Vasospasm in Traumatic Subarachnoid Hemorrhage

Objective: To report a rare case of delayed vasospasm (on Day 14) after traumatic subarachnoid hemorrhage. Background: Cerebral vasospasm is a main cause of disability after subarachnoid hemorrhage (SAH). Of the minimal research available about vasospasm in traumatic SAH (tSAH), it has been known to occur usually in first 10 days following the trauma with peak incidence on 3–5th day. Design/Methods: 72-year-old man admitted for management of tSAH and facial fractures after he was found down. Hospital course was complicated with cardiac arrest, myocardial infarction s/p percutaneous intervention and sepsis. Neurology was involved on day 14 for an episode of altered mentation associated with left sided weakness, dysarthria and nystagmus. MRI Brain without contrast showed stable tSAH in left sylvian and perisylvian region, multiple small areas of diffusion restriction, some associated with hemorrhage concerning for posttraumatic contusions and/or acute cardio embolic infarcts. MRA head was unremarkable. Continuous EEG did not show seizures or any epileptiform activity but due to transient episode of neurologic deficits, he was started on leviteracetam. Patient had a second episode of altered mentation and unequal pupils on day 18. His leviteracetam was increased however, repeat EEG also did not show any seizures. Repeat MRI brain was stable but MRA head revealed irregularities in the left middle cerebral artery M2 branches concerning for vasospasm. 4 vessel angiogram confirmed the presence of vasospasm which improved after intra-arterial verapamil. Nimodipine was briefly administered along with blood pressure management and then discontinued as patient was neurologically stable. Results: Our patient had delayed vasospasm on day 14 of tSAH. Conclusions: Vasospasm can increase the mortality and morbidity in patients with tSAH. Mechanism is poorly understood but thought to be due to inflammatory cascade triggered by hemoglobin degradation. More studies on the predictors, outcomes and treatment of vasospasm following tSAH are needed. Disclosure: Dr. Sharma has nothing to disclose. Dr. Sheng has nothing to disclose. Dr. Veerapaneni has nothing to disclose. Dr. Elkhider has nothing to disclose. Dr. Haldal has nothing to disclose. Dr. Patrice has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Nalleballe has nothing to disclose. Dr. Kapoor has nothing to disclose.