ABSTRACT NUMBER: ESOC2026A2120 THE IMPORTANCE OF URGENT GOAL-DIRECTED ULTRASOUND FOR DIAGNOSIS OF CEREBRAL VASOSPASM IN A CASE OF CT-NEGATIVE SUBARACHNOID HEMORRHAGE

Abstract Background and aims Spontaneous subarachnoid hemorrhage (SAH) carries 30% mortality, which doubles after rebleeding. Urgent diagnosis and treatment may improve the outcome. However, rare cases of CT-negative SAH pose a diagnostic challenge. Early detection of cerebral vasospasm is of great importance in preventing poor functional outcomes and death. We present a case of CT-negative SAH with vasospasm, initially diagnosed by cerebrovascular point-of-care ultrasound (POCUS). Methods A 38-year-old man was admitted due to acute left arm weakness two hours before. The clinical history included arterial hypertension, associated headache episodes, and transient weakness of the left leg one week earlier. Neurological examination revealed mild left hand paresis. Unenhanced brain CT was normal, and intravenous thrombolysis was initiated with a 7mg bolus of Alteplase. However, subsequent CT angiography revealed an unruptured aneurysm of the right internal carotid artery (ICA). Thrombolysis was discontinued. Results Goal-directed transcranial color-coded duplex sonography (TCCS) revealed a vasospasm of the right middle cerebral artery (MCA), Lindegaard index 3.2. A lumbar puncture was negative for xanthochromia. Five hours later, repeated TCCS showed an increase in Lindegaard index up to 6.8. Nimodipine was administered. After 2 days, MR imaging confirmed a ruptured ICA aneurysm, SAH, vasospasm, and ischemia in the right MCA area. Urgent aneurysm clipping was performed without complications. Conclusions New concept of POCUS in neurology is of great importance, differentiating the etiology of acute stroke. In a case of a CT-negative subarachnoid hemorrhage, non-invasive and easily repeatable cerebrovascular POCUS can detect vasospasm, impacting further treatment of the patient. Conflict of interest Jurgita Valaikiene: nothing to disclose; Carlotta Klingebiel: nothing to disclose; Elisa Maria Kazemekas: nothing to disclose; Saulius Taroza: nothing to disclose.