Diagnosis of symptomatic cerebral vasospasm after subarachnoid hemorrhage with minor blood leakage: a case report

Abstract

It is believed that the development of cerebral vasospasm is unlikely after minor blood leakage and subarachnoid hemorrhage. Additionally, it is quiet common that cerebral vasospasm occurs at a high rate in double hemorrhage and vasospasm models based on animal experiments. We diagnosed a case of delayed diagnosis of subarachnoid hemorrhage in a 37-year-old man. He experienced two episodes of severe headache that was suspected to have resulted from minor blood leakage. Additionally, he developed cerebral infarction in the left middle cerebral artery territory caused by cerebral vasospasm. On admission, he had cerebral infarction with dysarthria and right hemiplegia. On magnetic resonance imaging (MRI), the infarction at the perforating branch of the left anterior choroidal artery was identified, and on magnetic resonance angiography, cerebral vasospasm at the left middle cerebral artery was identified. Additionally, an aneurysm was detected in the left internal carotid artery on angiography of the posterior communicating artery bifurcation. Initially, subarachnoid hemorrhage was not identified on head computed tomography. A fluid attenuation inversion recovery MRI image of the head showed a small hematoma in an ambient cistern. Clipping surgery was performed 16 days after the second headache. Intraoperatively, the left Sylvian fissure was covered with a thick arachnoid membrane that indicated xanthochromia. We performed clipping of the ruptured aneurysm in the left internal carotid artery at the posterior communicating artery bifurcation. After rehabilitation, the patient was able to walk independently and discharged. This case study indicates the possible occurrence of cerebral vasospasm after double hemorrhage, even with minor blood leakage.