CHEST Guidelines-A-Patient-With-a-Subarachnoid-Hemorrhage-After-End

A-Patient-With-a-Subarachnoid-Hemorrhage-After-End

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The document discusses a clinical case involving a man in his 50s with a history of hypertension and methamphetamine abuse, who presented with a severe headache and was diagnosed with a high-grade subarachnoid hemorrhage (SAH) and acute hydrocephalus. During transportation to a triage center, his condition deteriorated, exhibiting symptoms such as flexor posturing, hypertension, and bradycardia, leading to intubation and administration of intravenous mannitol. Upon arrival, with a Glasgow Coma Scale score of 3, an external ventricular drain (EVD) was placed, resulting in some neurological improvement.<br /><br />The patient underwent endovascular coiling of a basilar-tip aneurysm but postoperatively faced complications including respiratory failure and a possible seizure. On the third postoperative day, no vasospasm was noted, but the EVD stopped functioning, and ultrasonographic examination revealed an increase in optic nerve sheath diameter (ONSD), suggesting increased intracranial pressure (ICP). A subsequent EVD replacement confirmed high ICP. Following this procedure, ultrasonography showed a decrease in ONSD, indicating reduced ICP.<br /><br />This case highlights the use of point-of-care ultrasound (POCUS) to assess ICP changes via ONSD measurement, especially when conventional CT scans fail to indicate such conditions. The patient was also associated with Terson syndrome, characterized by intraocular hemorrhage in the context of SAH, which was confirmed through an ophthalmologic examination showing significant vitreous hemorrhages.<br /><br />Throughout the 3.5-month hospital course, the patient's condition was complicated by respiratory issues such as pneumonia and suspected neurogenic pulmonary edema, requiring tracheostomy and nutritional support. However, he eventually showed significant recovery, with improved alertness and communication, although he remained wheelchair-bound and experienced limited visual acuity. This case underscores the diagnostic value of POCUS in managing complex neurosurgical cases involving SAH.

Keywords

subarachnoid hemorrhage

hypertension

methamphetamine abuse

intracranial pressure

point-of-care ultrasound

external ventricular drain

basilar-tip aneurysm

Terson syndrome

neurogenic pulmonary edema

Glasgow Coma Scale