(756) Ventriculitis Leading to Diffuse Vasospasm: An Atypical Complication

Introduction: Placement of an external ventricular drain (EVD) is common in the Neuro ICU. While lifesaving, this can be a potential source of infection, causing bacterial ventriculitis in 5-22% of cases. Although ventriculitis itself can be devastating, carrying a 30-71% mortality rate, it can lead to the exceedingly rare complication of cerebral vasospasm and infarction. Due to its rarity, there are no clear recommendations on monitoring for this complication. We describe a case of ventriculitis associated with vasospasm and cerebral infarction requiring decompressive hemicraniectomy.

Description: A 33-year-old male presented with headache and encephalopathy. Initial CT head demonstrated a right frontal intraparenchymal hemorrhage with intraventricular extension resulting in obstructive hydrocephalus. He was intubated and underwent EVD placement. In the following days, his improvement resulted in extubation and EVD removal. However, on hospital day (HD) 13, the patient developed left sided tonic movements with high fever. CSF was cultured (eventually growing Proteus mirabilis) and he was initiated on antibiotics. He was treated for seizures and connected to continuous electroencephalogram monitoring (cEEG). On HD 15 the patient further deteriorated with worsening encephalopathy and new right hemiparesis. At the time, cEEG exhibited diffuse slowing without seizures. Repeat CTH demonstrated a new left hemispheric stroke. CTA head revealed multiple vessels with decreased caliber concerning for diffuse vasospasm. The patient underwent digital subtraction angiography with intra-arterial delivery of nicardipine. Unfortunately, he developed severe left hemispheric cerebral edema requiring a decompressive hemicraniectomy. He was eventually discharged with deficits of aphasia, dysarthria, and quadriparesis.

Discussion: Ventriculitis induced vasospasm is a rare complication sparsely mentioned in literature. While cEEG has a high sensitivity in predicting vasospasm before clinical onset, no focal changes were observed. This case demonstrates that a high index of suspicion is required to detect this complication, even when not preceded by cEEG changes. Therefore, vasospasm should be considered in patients with ventriculitis, especially if they have unexplained new or worsening focal neurological deficits.