CHEST Guidelines-A-Patient-With-a-Subarachnoid-Hemorrhage-After-End (1)

A-Patient-With-a-Subarachnoid-Hemorrhage-After-End (1)

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In this medical case study, a man in his 50s was diagnosed with a high-grade subarachnoid hemorrhage (SAH) and acute hydrocephalus. His medical history included hypertension and methamphetamine abuse. His condition worsened during transport to a triage center, requiring intubation, administration of IV mannitol, and an emergent external ventricular drain (EVD) placement. Despite these interventions, the subsequent post-operative period included complications like hypoxemic respiratory failure and a potentially suspect seizure.<br /><br />Routine transcranial Doppler and head CT scans showed no vasospasm and a stabilization in ventricular size. However, the patient's neurologic examination remained inconclusive due to sedation and mechanical ventilation. His EVD also stopped functioning, prompting a POCUS examination to assess the optic nerve sheath diameter (ONSD). A significant increase was noted, suggestive of elevated intracranial pressure (ICP). This was initially hypothesized and led to the replacement of the EVD. Subsequently, ultrasonography indicated a decrease in ONSD, aligning with reduced ICP.<br /><br />The patient was further diagnosed with Terson syndrome, a condition associated with intraocular hemorrhage amid intracranial hemorrhages, alongside vitreous hemorrhages discovered through ophthalmological evaluation. Despite complications, including respiratory failure resultant from pneumonia, neurogenic pulmonary edema, and Clostridium difficile infection, the patient eventually showed clinical improvement and was discharged with considerable recovery in consciousness, albeit with continued visual limitations.<br /><br />The case highlights the possible underdiagnosis of Terson syndrome in SAH patients and underscores the utility of ocular ultrasonography in detecting increased ICP when traditional CT scans may fall short. Nonetheless, while the probe's ability to correlate ONSD with ICP is promising, methodological controversy persists and necessitates further investigation for standardization.

Keywords

subarachnoid hemorrhage

acute hydrocephalus

hypertension

methamphetamine abuse

external ventricular drain

optic nerve sheath diameter

intracranial pressure

Terson syndrome

ocular ultrasonography

neurogenic pulmonary edema