To describe diffuse vasospasm following spontaneous lobar intracerebral hemorrhage (ICH), refractory to intraarterial verapamil and treated with angioplasty, and review existing literature on vasospasm after ICH.

A 50-year-old male with complex congenital heart disease, including a mechanical valve on warfarin, presented with right hemiplegia and aphasia due to a large spontaneous left frontal lobar ICH. He underwent craniotomy and hematoma evacuation. Interval serial imaging demonstrated resolving hematoma with intraventricular extension and layering of blood in the occipital horns, and his neurologic exam improved with time. He developed self-resolving hematochezia after resumption of anticoagulation. Days later, he was increasingly somnolent, progressing abruptly to obtundation. CT angiography demonstrated diffuse multifocal narrowing of intracranial anterior and posterior circulation vessels, consistent with vasospasm.

Conventional angiography showed severe and flow limiting anterior and posterior circulation vasospasm. Intraarterial verapamil was administered with improvement in caliber. MRI revealed infarcts in the superior pons, bilateral thalami, and punctate infarcts in the bilateral anterior circulation. Hemodynamic augmentation with norepinephrine and milrinone was instituted. Ongoing coma prompted three repeat angiograms. Due to persistent vasospasm despite two additional intraarterial verapamil treatments, angioplasty of the posterior circulation was ultimately performed. Interval transcranial doppler showed improving vasospasm with continued neurologic recovery. CT angiography weeks later confirmed complete normalization of vessel caliber.

Delayed vasospasm, common following aneurysmal subarachnoid hemorrhage, can rarely occur following primary ICH. It has been infrequently seen after spontaneous intraventricular hemorrhage (IVH) due to circulation of blood breakdown products within cerebrospinal fluid. Primary ICH resulting in vasospasm is extremely uncommon; we identified only one prior report and one study describing three cases, all with concomitant IVH. Post-craniotomy vasospasm, typically seen after craniotomy for tumor resection, may have contributed. Secondary clinical deterioration in patients with primary ICH, especially if IVH is present, should prompt consideration of angiography to assess for vasospasm.