Category: Clinical Sciences/Health Conditions
Cerebral vasospasm in the setting of intracerebral hemorrhage (ICH) with intraventricular hemorrhage (IVH)
61-year-old man admitted to inpatient rehabilitation (IPR) following a spontaneous left temporo-occipital ICH with IVH. On acute hospital day (HD) 2 the patent underwent an angiography that did not reveal a source of bleeding. His external ventricular drain (EVD) was removed on acute HD 12. The patient was discharged on HD 13 to IPR. On IPR HD 3, during interdisciplinary conference, the therapy team noted the patient was exhibiting new paradoxical left hemispatial neglect which did not anatomically correspond with the diagnosis of left ICH. Physical examination revealed a drowsy patient with a new left hemispatial neglect with a right gaze preference. CT angiogram revealed diminutive caliber of the bilateral proximal A1 and M1 segments which was consistent with cerebral vasospasm.
When physical examination findings are conflicting with the expected findings based on radiographical anatomy further evaluation is warranted and a broad differential diagnosis should be considered. Strong interdisciplinary teamwork is a hallmark of effective rehabilitation management and encouraging all members of the team to feel comfortable reporting concerns noted on therapy or nursing evaluations is vital. Active listening and addressing therapy team concerns improves the effectiveness of medical care provided on the rehabilitation unit. While ICH is not commonly associated with cerebral vasospasm, practitioners treating patients with ICH should be aware of the risk of cerebral vasospasm associated with IVH. While the true incidence of cerebral vasospasm secondary to ICH with IVH is not well described one study reported cerebral vasospasm in 5.6% of patients.
Physical exam findings should be correlated to radiographic anatomy and if discordant further evaluation should be conducted. If a patient with ICH with IVH experiences a clinic deterioration during IPR cerebral vasospasm should be considered in the differential diagnosis.