Multimodal Monitoring in Eclamptic Intracerebral Hemorrhage Complicated by Reversible Cerebral Vasoconstriction Syndrome (RCVS): A Case Report.

BACKGROUND

Eclampsia is a rare but severe obstetric condition associated with maternal morbidity and mortality. Neurological complications are rare and often compounded by systemic involvement such as HELLP syndrome and coagulopathy. In this complex setting, multimodal neuromonitoring may support individualized management.

CASE: A 32-year-old woman at 37 weeks' gestation presented with new-onset tonic-clonic seizures, severe hypertension, and laboratory findings consistent with HELLP syndrome and disseminated intravascular coagulation. Following emergency cesarean section, brain CT revealed a right frontal intracranial hemorrhage (ICH) with mass effect. Given the high surgical risk related to coagulopathy, conservative management was pursued after placement of an invasive intracranial pressure (ICP) monitoring. In the neuro-ICU, a multimodal monitoring strategy combining ICP waveform analysis, continuous electroencephalography, cerebral near-infrared spectroscopy, and transcranial color-coded duplex ultrasound (TCCD) guided therapy. Medical treatment successfully controlled intracranial hypertension and restored cerebral compliance. Daily TCCD examinations revealed progressively increased middle cerebral artery flow velocities, leading to early suspicion and radiological confirmation of reversible cerebral vasoconstriction syndrome (RCVS). Treatment with verapamil and levosimendan resulted in rapid normalization of Doppler velocities without systemic hypotension.

OUTCOME: The patient showed progressive neurological recovery and was discharged to rehabilitation. After 6 months, functional outcome was favorable (modified Rankin Scale = 2).

CONCLUSIONS

This case underscores the value of bedside TCCD integrated with multimodal neuromonitoring in the management of a complicated eclampsia with ICH and RCVS. Assessment of cerebral hemodynamics and perfusion may support safe conservative management in high-risk neuro-intensive care patients.