Hypertensive-Nimodipine Therapy for Middle Cerebral Artery Vasospasm after Resection of Glioblastoma Multiforme: A Case Report and Literature Review

Abstract

Delayed cerebral ischemia (DCI) due to post-brain tumor resection vasospasm is an often unrecognized yet debilitating complication. We present a patient with DCI after the resection of glioblastoma multiforme (GBM). To our knowledge, this is the first report on DCI after GBM resection. A 52-year-old female patient with headache for one month underwent subtotal resection of a left temporal GBM encasing the proximal middle cerebral artery (MCA). She was well during the immediate postoperative period but developed right upper limb dense monoparesis on postoperative day four with computed tomographic angiography confirming left MCA vasospasm. Symptoms were significantly alleviated with weeklong hypertensive therapy and nimodipine administration; however they recurred soon after cessation of treatment. A high index of clinical suspicion is needed for the diagnosis of post-tumor resection DCI. Any new postoperative neurological deficit that cannot be explained by hemorrhage, seizures or infection should be expeditiously investigated by angiography or transcranial Doppler sonography. Prompt initiation of hypertensive and nimodipine therapy can possibly reverse neurological deficit. Treatment should be guided by Doppler, angiographic or perfusion imaging studies and not by clinical improvement alone.

Symptomatic cerebral vasospasm in the setting of carmustine wafer placement for glioblastoma: A case presentation and review of literature

“…CVS is a well-described entity in patients with aneurysmal subarachnoid hemorrhage (aSAH) [4,8,10,34] and following epilepsy surgery, [11,19,20,24] but its incidence in the postoperative course of tumor resection is low. [7] Bejjani et al conducted a retrospective review of 470 patients with skull base tumors and noted 1.9% incidence of CVS postoperatively.…”

“…[21] Woo et al recommended continued radiographic surveillance of CVS with TCDs and/or angiographic imaging, though the correlation between radiographic CVS and persistent symptoms is still unclear. [19,33,34] We urge clinicians to maintain a high suspicion for sCVS postoperatively in patients with delayed neurological deficits after Gliadel wafer placement in high-grade glioma. We propose the early use of CT angiography in this patient population.…”