Subarachnoid Hemorrhage
Patient Presentation:
C.D., a 41 yo female with no significant past medical history was admitted to the hospital after the onset of a frontal headache with associated vomiting and worsening headache. Pt. had a grand mal seizure during the hospital admission and became unresponsive. CT scan at that time revealed SAH with blood in the cisterns, aqueduct, and fourth ventricle. Pt. was intubated and transferred to specialty hospital by helicopter.
Diagnosis:
Subarachnoid Hemorrhage due to ruptured aneurysm.
Treatment:
Pt. was admitted to neurosurgery service and a right frontal EVD (External Ventricular Drain) was placed with opening pressure of 25 cm of water. Pt was then taken to the endovascular suite and a small “bump” 1mm deep by 2.5mm wide was found on the left A1 vessel. Keppra® for seizure ppx was started and blood pressure was maintained with a nimodipine drip. The following day the pt. self-extubated and did well with GCS (Glasgow Coma Scale) of 13 but pt was reintubated and taken to the OR for left pterional craniotomy and clipping of A1 aneurysm.
Post operatively pt was oriented x1, ICP post op was 13 and EVD continued to produce 80-120ml of CSF per 8 hour shift. CT scan following surgery showed post-op changes, post-op left pterional craniotomy. Trans-cranial Dopplers were within normal limits and ventilator was weaned and pt extubated the following day.
Pt continued to be oriented x1 2 days post op. Pt. was cleared for regular diet with thin liquids. Three days post op pt had angiography which revealed mod-severe left M1 vasospasm and mild right ICA and mod basilar artery vasospasm. Verapamil was administered in the OR via femoral catheter. Following this procedure patient continued to be febrile without known source despite multiple cultures (including CSF cx). Hypertonic saline was administered in boluses and via drip for hyponatremia.
Tylenol® was given for the fever without relief. Neo and dopamine were titrated to keep systolic blood pressure between 160 and 180 to try and prevent vasospasm. Pt. was also on a 21 day course of nimodipine which decreases blood pressure. (Prior to surgery - kept BP and volume low to reduce bleeding at hemorrhage site, after surgery try to keep BP and volume elevated, with hemodilution to prevent vasospasm).
Pt. continued to have severe spasms of left M1 and returned to the OR to receive verapamil day 5 and day 7 post op. Day 8 post op pt. underwent balloon angioplasty and verapamil injection due to severe spasm of left M1. Day 16 post op the EVD drain was removed and all central lines. Sodium normalized to 137 on post op day 19. The pt. completed a 21 day course of nimodipine. 21 days post op the patient was transferred to medical floor and seen by PT/OT.
Outcome:
Pt. was discharged to an inpatient rehabilitation facility. It is estimated that she will be there for 2-4 weeks before switching to day therapy. Noted impairments included ataxia, fatigue, generalized decreased strength, endurance, and balance. Decreased mobility, ability to transfer self, and ambulate. Decreased ability to reintegrate into community, decreased communication and problem solving abilities. Nursing, occupational, physical, speech, psychology therapy goals were identified.