Delayed traumatic pseudoaneurysm formation, severe cerebral vasospasm, and delayed cerebral ischemia after traumatic subarachnoid hemorrhage: a case report

Traumatic subarachnoid hemorrhage is common after traumatic brain injury, but clinically significant vasospasm with delayed cerebral ischemia is less clearly defined in this setting than after aneurysmal subarachnoid hemorrhage.We report the case of a 77-yearold man who presented with drowsiness after being injured as a pedestrian in a traffic accident.Initial computed tomography (CT) showed diffuse traumatic subarachnoid hemorrhage, intraventricular hemorrhage with hydrocephalus, skull base and facial bone fractures, and small extra-axial hemorrhages.Initial CT angiography identified neither an aneurysm nor a significant steno-occlusive lesion.Despite early intravenous administration of nimodipine, delayed vascular imaging revealed new multifocal arterial narrowing in the left middle cerebral artery, both anterior cerebral arteries, and distal branches of both middle cerebral arteries, as well as possible basilar artery narrowing.Diffusion-weighted magnetic resonance imaging showed acute infarctions in the anterior and middle cerebral artery territories bilaterally; CT perfusion showed perfusion abnormalities in both cerebral hemispheres.Vasospasm was treated with intra-arterial nimodipine infusion, followed by stent-assisted treatment of a newly detected left paraclinoid pseudoaneurysm.Severe disability persisted during long-term follow-up.This case suggests that severe vasospasm with delayed cerebral ischemia may develop after traumatic subarachnoid and intraventricular hemorrhage despite negative initial angiography and prophylactic nimodipine administration.