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Washington University Experience | VASCULAR | Aneurysm - Saccular | 11A0 Case 11 History
Case 11 History ---- The patient was a 72 year old diabetic hypertensive woman who suddenly fell at home and was unable to call for help. At her local hospital she was found to be lethargic unable to converse. At that time she was said to have had a left upgoing toe and unequal pupils. Later that day she became decerebrate and was noted to have dilated pupils, Cheyne Stokes respiration, and a blood pressure of 220/140. She was transferred to the Barnes Hospital ER. Neurological examination revealed the patient to be comatose whose response to deep pain was decerebration on the left side. Both legs were in extension. Deep pain to both limbs produced triple flexion. A large hemorrhage was noted in the right fundus, only response to caloric stimulation was short duration downward nystagmus, pupils were 3 mm's and non-reactive. Corneal and gag reflexes were present. Her admitting CBC, SMA6, and arterial blood were within normal limits. A stat CT scan revealed an intraventricular hemorrhage forming a cast of the third and fourth ventricles. The blood had extended into the subependymal layers of the floor of the right ventricle and to lesser extent the left ventricle. There was a small amount of blood in the inter hemisphere fissure and in the left circular sulcus on the surface of the medulla. It was felt by the radiologist that the primary source of hemorrhage was in the third ventricle or close to the lamina terminalis as an anterior communicating aneurysm. There was also a significant degree of hydrocephalus. No parenchymal hemorrhage was seen. Lumbar puncture was attempted and finding an opening pressure of 200 and pink fluid, no fluid was collected. At that point the patient was felt to have a severe subarachnoid intraventricular hemorrhage probably secondary to aneurysm and the patient was begun on 20% mannitol and intravenous Decadron. By two days post admission the patient was able to move both legs purposefully, to grimace to deep pain and because of this slight improvement the Amicar was continued. She was able to respond to voice by the 5th day in the hospital, open her eyes and say short sentences. On the 7th hospital day the patient became more lethargic and the left disc margin began to blur. It was felt that was probably due to hydrocephalus, secondary to the subarachnoid bleed. Before a CT could be done the patient was noted to have blood pressure of 220/120, and became comatose with no response to verbal command. Pupils were 3 mm bilaterally, doll's eyes remained present but some extensor posturing was noted in the lower and upper extremities. By the ninth hospital day the patient developed upper airway bleeding. The CT scan at that time revealed change in ventricular size and CNS re-bleed could not be ruled out because the ventricles were still filled with blood from the first bleed. By the 10th hospital day her fever increased to 40°C, and a right middle lobe infiltrate was noted. Her prognosis was considered grave at that time, and she was treated symptomatically with a cooling blanket and tylenol. She expired later that day.
