Intracranial Vasospasm After Evacuation of Acute Spontaneous Subdural Hematoma

Abstract

Cerebral vasospasm is a well-known entity following aneurysmal subarachnoid hemorrhage. While it has been described in trauma, it has been much less studied. There have been no previous reports of cerebral vasospasm following spontaneous subdural hematoma or after subdural hematoma evacuation. In this case report, we present a 38-year-old otherwise healthy female who suffered an acute spontaneous subdural hematoma. After surgical evacuation of her hematoma, she developed neurologic decline. Computer tomography angiography demonstrated intracranial vasospasm. She was treated with blood pressure augmentation and nimodipine. She went on to make a full neurologic recovery.To our knowledge, this is the first reported case of cerebral vasospasm after acute spontaneous subdural hematoma or after subdural hematoma evacuation, and the patient recovered without sequelae. The promising outcome of this case may provide a framework for future similar cases. Neurosurgeons and intensivists should keep cerebral vasospasm in their differentials for patients who have neurologic decline after craniotomy for acute subdural hematoma and have an otherwise negative scan for new acute abnormality.

Keywords: acute subdural hematoma; delayed ischemic neurological deficit; intracranial vasospasm; spontaneous subdural hematoma; subdural hematoma evacuation.

Figure 1. Spontaneous acute subdural hematoma.

(A) Subdural hematoma at initial hospital presentation. (B) Interval increase of subdural hematoma four days after initial presentation. (C) One-day post-operative head CT demonstrating improved midline shift. (D) CT head on the post-operative day 2 demonstrating increased midline shift but without significant acute blood or other compressive etiology.

Figure 2. Development of cerebral vasospasm after subdural hematoma evacuation.

(A, B) Axial and coronal views, respectively, demonstrating preoperative cerebral vasculature. Vessels appear normal caliber. (C, D) Vasospasm is noted in the L>R supraclinoid and L anterior cerebral and middle cerebral arteries when compared to the preoperative CT angiogram (white arrows). The cortical branches also have notably less filling.