Postoperative rehabilitation for cerebral vasospasm leading to malignant MCA infarction following aneurysmal intracerebral haemorrhage

Dinesh*

Physiotherapist, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

*Correspondence

Abstract

Aneurysmal intracerebral haemorrhage (ICH) is a life-threatening neurological emergency associated with significant morbidity and mortality. Cerebral vasospasm is a well-recognized postoperative complication that can result in delayed cerebral ischemia (DCI) and large territorial infarction. We report the case of a 52-year-old male who presented with aneurysmal ICH and underwent successful surgical clipping. Despite an initially stable postoperative course, he developed acute neurological deterioration on postoperative day (POD) 2 due to early severe vasospasm, leading to malignant middle cerebral artery (MCA) infarction. Emergency decompressive craniectomy and tracheostomy were performed, resulting in survival with residual hemiplegia. This case highlights the importance of early recognition of vasospasm, vigilant neurological monitoring, prompt imaging, and aggressive multidisciplinary intervention, including structured neurorehabilitation.

Keywords: Aneurysmal intracerebral haemorrhage; Cerebral vasospasm; Delayed cerebral ischemia; Malignant MCA infarction; Decompressive craniectomy; Neurorehabilitation; Early physiotherapeutic interventions.

Introduction

Aneurysmal rupture most commonly presents as subarachnoid haemorrhage (SAH), but may also be associated with intracerebral haemorrhage, significantly worsening prognosis. One of the most serious complications following aneurysmal rupture is cerebral vasospasm, which occurs in up to 70% of patients, with approximately 20–30% developing clinically significant delayed cerebral ischemia (DCI).

Case Presentation

A 52-year-old male presented with acute onset of severe headache and vomiting. On admission, the patient was conscious with a normal Glasgow Coma Scale (GCS-14/15) score and no focal neurological deficits.

Investigation

CT Brain: Revealed right-sided intracerebral haemorrhage

CT Angiography: Confirmed aneurysmal ethology

MRI brain & MRA brain

A diagnosis of aneurysmal intracerebral haemorrhage was established

(6/3/26)

Management

The patient underwent surgical clipping of the aneurysm on 6/3/26 and was electively ventilated postoperatively, with maintenance of sedation and neuromuscular paralysis. On the second postoperative day, the patient developed sudden bilateral pupillary dilatation with non-reactive pupils. An urgent repeat CT scan of the brain revealed a large right middle cerebral artery (MCA) territory infarction, consistent with severe cerebral vasospasm. Emergency measures were promptly undertaken, including a decompressive craniectomy and tracheostomy ( 9/3/26) for prolonged ventilatory support. Following the second intervention, the patient showed clinical improvement, with pupils becoming normal and reactive by postoperative day 2, and the patient regaining consciousness by postoperative day 4.

Neurological Status

  • Persistent dense left-sided hemiplegia
  • Built of the patient: endomorphic

Rehabilitation and Follow-Up

  • Hemodynamically stable
  • Receiving respiratory support via T-piece and BiPAP, with gradual weaning
  • Structured and comprehensive rehabilitation program was implemented to address generalized weakness, impaired airway clearance, reduced joint mobility, altered muscle tone, and functional limitations.
  • To facilitate airway clearance, chest physiotherapy techniques, including percussion and vibration, were administered at regular intervals. This was complemented by frequent suctioning and appropriate positioning strategies to enhance secretion drainage and prevent secondary complications such as pressure sores.
  • Muscle tone and joint mobility were maintained through passive range of motion exercises. Joint proprioception and weight-bearing responses were further promoted using graded compression techniques, including assisted standing and passive movements with applied compression.
  • Early mobilization strategies were incorporated as part of functional rehabilitation. Tilt table therapy was initiated to improve orthostatic tolerance, enhance hemodynamic stability, and facilitate gradual verticalization. Assisted standing was performed to promote weight-bearing, stimulate postural muscle activation, and improve proprioceptive input. Additionally, daily chair sitting for approximately two hours was encouraged to improve sitting tolerance, postural control, and functional endurance.
  • Patient having right sided neck stiffness, for right-sided cervical stiffness, targeted neck stretching and passive cervical mobilization were performed to reduce muscle tightness and improve range of motion.

Simultaneously, oral feeding trials were initiated as part of the swallowing rehabilitation program. These were introduced in a graded manner under close supervision, focusing on safety and tolerance. The patient demonstrated progressive improvement in oral intake over time, indicating recovery of swallowing function and reduced dependency on alternative feeding methods.

Muscle powerRight upper &lower limbLeft upper &lower limb
Pre rehab2+0
On rehab4+1 (for pain stimulus)

Recommendations and Further Management

  • In the ongoing phase, rehabilitation should focus on maximizing functional independence, promoting neuroplasticity, and preventing complications. Neuromuscular electrical stimulation may be used to facilitate muscle activation and support motor recovery.
  • Progressive weight-bearing activities, including supported and splint-assisted standing, should be continued to improve postural control and prevent contractures. Gait training with a walker should be advanced, emphasizing balance, coordination, and endurance.
  • Functional mobility training, including bed mobility and transfer techniques, should be practiced enhancing independence. Toileting training, incorporating scheduled voiding and safe transfer strategies, should be included to promote personal autonomy.

 

 

Discussion

Cerebral vasospasm is a well-recognized complication following aneurysmal haemorrhage, typically occurring between days 3 and 14 post-rupture, and is a major contributor to delayed cerebral ischemia and poor neurological outcomes. In this case, early postoperative neurological deterioration was identified through changes in pupillary response, prompting urgent imaging that confirmed a right middle cerebral artery infarction secondary to severe vasospasm. The timely decision to perform decompressive craniectomy proved lifesaving and significantly influenced the patient’s subsequent recovery. This case underscores the importance of vigilant neurological monitoring following aneurysm clipping, the need for early detection and prompt management of vasospasm, the value of repeat neuroimaging in the setting of acute deterioration, and the benefit of aggressive surgical intervention in cases of malignant infarction. Furthermore, the rehabilitation program was individualized, goal-directed, and progressively advanced based on continuous clinical assessment. This comprehensive approach aimed to optimize neurological recovery, enhance functional independence, and improve overall quality of life.

Conclusion

Aneurysmal intracerebral haemorrhage can be complicated by severe vasospasm leading to malignant infarction. Early recognition and timely surgical intervention can significantly improve survival, though long-term neurological deficits may persist. Multiple physical therapy rehabilitation approaches is essential for functional recovery.

References

  • Dhar R, Diringer MN. Management of aneurysmal subarachnoid hemorrhage in the modern era. Critical Care Clinics. 2024;40(1):85–102.
  • Langefeld CD, Comeau ME, et al. Advances in the management of aneurysmal subarachnoid hemorrhage and vasospasm. Lancet Neurology. 2024;23(3):250–262.
  • Lawton MT, Vates GE. Subarachnoid hemorrhage. New England Journal of Medicine. 2023;388(2):157–168.
  • American Heart Association Stroke Council. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage. Stroke. 2023;54(7):e314–e370.
  • Geraghty JR, Testai FD. Delayed cerebral ischemia after subarachnoid hemorrhage: current management and future directions. Current Atherosclerosis Reports. 2023;25(4):215–224.
  • Neurocritical Care Society. Guidelines for the evaluation and management of cerebral vasospasm and delayed cerebral ischemia. Neurocritical Care. 2023;38(Suppl 1):1–45.
  • Rowland MJ, Hadjipavlou G, Kelly M, Westbrook J, Pattinson KTS. Delayed cerebral ischemia after subarachnoid hemorrhage: looking beyond vasospasm. Brain. 2023;146(5):e38–e42.

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