CHEST Guidelines-A-Patient-With-a-Subarachnoid-Hemorrhage-After-End (2)

A-Patient-With-a-Subarachnoid-Hemorrhage-After-End (2)

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The document discusses a clinical case of a man in his 50s who presented with a severe headache and was diagnosed with a high-grade subarachnoid hemorrhage (SAH), further complicated by acute hydrocephalus. During transport, his condition deteriorated, leading to intubation and administration of IV mannitol. On arrival at a triage center, an external ventricular drain (EVD) was placed following a Glasgow Coma Scale score of 3, leading to clinical improvement. The patient also underwent successful endovascular coiling of a basilar-tip aneurysm.<br /><br />Postoperatively, his course was complicated by hypoxemic respiratory failure and a possible seizure. On postoperative day 5, the EVD stopped functioning. Sedation and mechanical ventilation limited neurological examination, but point-of-care ultrasound (POCUS) revealed an optic nerve sheath diameter (ONSD) suggestive of increased intracranial pressure (ICP).<br /><br />The term "Terson syndrome," which refers to vitreous hemorrhage associated with intracranial hemorrhage, is discussed as a potential diagnosis. Ophthalmological assessment confirmed multiple vitreous hemorrhages in both eyes. The EVD was replaced despite stable CT imaging, leading to a reduction in ONSD.<br /><br />This case emphasizes the utility of POCUS in detecting increased ICP when traditional imaging does not, supporting the prompt replacement of EVD resulting in clinical improvement. Terson syndrome is highlighted as often underdiagnosed but significant, correlated with poorer prognosis in SAH cases.<br /><br />Further discussions illuminate controversies in measuring ONSD and its correlation with ICP. The document calls attention to the need for careful application of ultrasound methods in clinical settings, considering the potential implications for patient management and outcome predictions.

Keywords

subarachnoid hemorrhage

acute hydrocephalus

external ventricular drain

endovascular coiling

optic nerve sheath diameter

intracranial pressure

Terson syndrome

point-of-care ultrasound

vitreous hemorrhage

clinical improvement