Subarachnoid Hemorrhage
Patient Presentation:
C.M., a 66 year old female arrived to the ED complaining of a severe headache, nausea, and vomiting for the past two days. The patient reveals she has taken Tylenol® and Motrin® but continues to experience “the worst headache of her life”. The patient is alert, neurologically intact, and has equal briskly reactive pupils. The patient’s Glasgow Coma Scale (GCS) is 15. The patient’s past medical history includes hypertension and diabetes mellitus. She admits she does not take her prescribed antihypertensive medications.
Vital signs: Temperature: 36.7, Heart Rate: 80, Blood Pressure: 210/96, O2 sat: 98%, Pain: 10/10 Headache.
Lab Results:
BMP: Na+ 137, K+ 3.9, Cl- 101, Mg++ 1.7, Phos 2.7, BUN 5, Creatinine 0.49, Ca++ 7.9, Glucose 135
CBC: WBC 10.8, RBC 2.66, Hgb 9.1, Hct 26.5, Platelets 287, INR 1.2
Differential Diagnosis:
Subarachnoid Hemorrhage, Migraine, Hemorrhagic Stroke
Diagnosis:
A CT scan without contrast is performed and reveals a subarachnoid hemorrhage. The patient is admitted to the Neurosurgical ICU for monitoring. Overnight the patient becomes lethargic and her pupils become non-reactive to light. Due to the decline in mental status an external ventricular drain (EVD) is placed and reveals an elevated intracranial pressure (ICP), (24mmHg). Due to her rapid decline in mental status, the patient is intubated and a neuro-vascular angiogram is performed to visualize the patient’s brain vessels. The angiogram reveals the source of the hemorrhage is a right posterior communicating aneurysm that has ruptured.
Treatment:
The patient is rushed to the OR where a right craniotomy is performed in order to clip the aneurysm. The procedure is successful and the patient returns to the ICU intubated. The patient receives normal saline at 150ml/hr IV, Propofol at 20mcg/kg/min IV for sedation, Phenytoin IV for seizure prophylaxis, and Nimodipine PO to prevent vasospasm.
Outcome:
Post operatively the patient’s ICP remains between 2-13mmHg. Two days after the craniotomy the patient is extubated. C.M. is neurologically intact and her pupils are equal and reactive. She does not suffer any long term neurological deficits and receives occupational therapy and physical therapy. She maintains full strength at all extremities. A post-operative MRI is performed and shows no new bleeding. The EVD is weaned and eventually removed. The patient and her family are educated about her diagnosis and the importance of adhering to physician’s orders concerning her sedentary lifestyle and prescribed anti-hypertensive medications. C.M. was transferred to a non-telemetry unit where she is awaiting discharge.
Case created by Carmen Moore, 2011.