Sean Zwicky, MD
Resident
Shirley Ryan Ability Lab
Chicago, Illinois, United States
Matthew C. Oswald, MD
Attending Physician
Shirley Ryan AbilityLab
Chicago, Illinois, United States
Neuropsychiatric sequela, including depression and anxiety, occur in 30% of patients after liver transplantation and can adversely impact rehabilitation and quality of life. Intracranial hemorrhages, while much less common, occur in 2% of patients in the first month following transplantation with significant morbidity and mortality.
A 58-year-old male with history of alcohol-related cirrhosis presented to inpatient rehabilitation (IPR) after admission for decompensated cirrhosis managed with orthotopic liver transplantation complicated by hemorrhagic shock and small subdural hemorrhage (SDH). Early rehabilitation course was complicated by worsening depression, anxiety, and suicidal ideation followed by acute encephalopathy with work-up revealing enlarging SDH with midline shift. Patient was transferred to acute care where he underwent a burr hole for hematoma evacuation. Patient later returned for continuation of IPR with improvement in his psychiatric symptoms.
During initial IPR course, patient developed nonspecific neuropsychiatric symptoms of depression, guilt, and passive suicidal ideation with poor rehabilitation participation. Given the absence of neurological deficits and recent radiographic demonstration of improving SDH, the patient’s symptoms were thought to be multifactorial with adjustment disorder following transplantation. He subsequently developed acute encephalopathy, leading to the discovery of an enlarging SDH on imaging and transfer for appropriate intervention. On return to IPR, patient demonstrated improved mood and participation in therapy. He progressed to a near-independent level for activities of daily living and functional mobility and was discharged home. Neuropsychiatric symptoms occur commonly in patients following liver transplantation but carry a broad differential given the many confounding factors these patients experience. It is critical to keep intracranial pathology on the differential given the high risk of mortality and morbidity.
We describe the case of a liver transplant recipient with an atypical, psychiatric presentation of SDH. This illustrates the diagnostic challenges of making the appropriate diagnosis when presented with common symptoms due to uncommon pathology.
