Reversible cerebral vasoconstriction syndrome with delayed vasospasms and subdural hematoma after cardiac transplantation: a case report.

BACKGROUND

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare but severe neurovascular complication following cardiac transplantation. Its diagnosis is often complicated by atypical presentations and by neuroimaging limitations, as transplant-related devices can hinder timely magnetic resonance (MR) imaging.

CASE PRESENTATION: A 59-year-old woman developed a severe headache 9 days post-cardiac transplantation. Neurological examination revealed left lower quadrantanopia. A head Computed Tomography (CT) scan showed a subdural hematoma, along with a subcortical and convexity subarachnoid hemorrhage in the right parieto-occipital lobe. Initial CT angiography showed only focal arterial stenosis. On day 10, she developed left hemineglect. After removal of transplant-related devices, MR imaging showed a watershed infarct and MR angiography revealed multiple vasospasms.

DIAGNOSTIC CHALLENGES: The diagnostic challenge was the delayed onset of diffuse vasospasms, the confirmation of which was precluded by the initial contraindication to MR imaging.

MANAGEMENT: The patient was diagnosed with RCVS. Management included withdrawal of tacrolimus and initiation of oral verapamil and prasugrel. This led to rapid clinical and radiological improvement.

CONCLUSION

This case highlights that RCVS can present with a subdural hematoma before the onset of delayed vasospasm after cardiac transplantation. Repeated cerebrovascular evaluations are crucial for timely diagnosis and management in post-transplant patients with unexplained headaches or intracranial hemorrhage.