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.