Patient Presentation:
KM, a 52 year old female, presented to the Emergency Department with complaints of sudden onset severe headache, nausea, vomiting, and photosensitivity that occurred while driving to work. KM reports 10/10 head pain that she describes as the worst headache of her life. Past medical history includes hypothyroidism, kidney stones, migraines, vitamin D deficiency, hypercholesterolemia, and 40-year smoking history. Other than presenting symptoms, KM’s neuro exam was normal: Glascow Coma Scale=15, pupils equal and reactive, moving all extremities with normal and symmetric strength. BP 140s/80s, HR 80-100 bpm, O2 saturation > 94% on room air, and febrile with temperature 38.6°C.
Differential Diagnoses:
Differential diagnosis includes stroke, migraine, tension headache, subarachnoid hemorrhage, epidural hematoma, meningitis, brain tumor.
Diagnosis:
Head CT revealed a subarachnoid hemorrhage (SAH) from aneurysm rupture located in the left superior hypophyseal artery (branch of internal carotid artery).
Treatment:
An External Ventricular Drain (EVD)/Ventriculostomy was placed in the left lateral ventricle in order to drain CSF and monitor ICP (Intracranial Pressure). KM was taken to Interventional Radiology, and underwent cerebral angiogram with coiling of aneurysm. Post-procedure, KM was admitted to the ICU for further management. EVD drainage system was set at height 10cm H20 relative to outer canthus of KM’s eye. CSF drainage and ICP’s were monitored every hour. Blood-tinged CSF drained at 4-17ml/hr. ICP’s ranged 1-7mmHg. KM was started on vancomycin (for fever and while EVD in place), Decadron® IV (to reduce inflammation), Keppra® IV (seizure prophylaxis), and nimodipine (calcium channel blocker to prevent cerebral vasospasms and subsequent ischemia). Fioricet® and fentanyl were administered for pain control, and Zofran® was given PRN for nausea. KM was started on a norepinephrine drip to maintain goal MAP 80-110.
Strict I&O’s, urine specific gravity, and serial serum sodium levels were monitored due to risk for development of diabetes insipidus. Urine output was elevated at 300-425ml/hr. Continued maintenance IV fluids of normal saline with 20mEq KCl at 125ml/hr, and encouraged PO intake of fluids (pt reported frequent thirst). Urine specific gravity = 1.005-1.010 and serum sodium = 141-144, so KM was not diagnosed with DI but monitoring continued.
On 3rd post-procedure day, KM developed increasing headache, nausea, and blurry vision. KM was hypertensive, but there were no other changes on neuro exam or ICP readings. CT was negative for increasing SAH. KM was taken to IR, which revealed vasospasm. Pt underwent angioplasty for treatment of vasospasm.
Outcome:
During ICU course, KM required 2 additional trips to IR for angioplasty to treat subsequent vasospasm episodes. EVD was removed after the 2nd week of hospitalization, KM no longer required norepinephrine, and Decadron® was tapered down. Nimodipine was continued for 3 weeks after aneurysm rupture. KM remained in the ICU for 3 weeks for frequent neuro monitoring and vasospasm watch. Then KM was transferred to the Neurological Intermediate Care Unit for step-down care.