Table of Contents
Washington University Experience | VASCULAR | Aneurysm - Saccular | 17A0 Case 17 History
Case 17 History ---- The patient was an 86 year old man admitted initially to an outside hospital (OSH) on 9-10-00 with right eye pain suspicious for ophthalmic zoster. While still hospitalized on 9-15-00, the patient fell, hit the back of his head, became poorly responsive. Head CT scan revealed subarachnoid hemorrhage in the basilar cisterns and hydrocephalus, treated by ventriculostomy on 9-15-00. Repeat head CT on 9-18-00 at the OSH revealed intraparenchymal hemorrhage in the frontal lobes bilaterally and subarachnoid blood. Cerebral angiogram performed on 9-19-00 revealed an 8.0 x 7.0 mm anterior communicating artery aneurysm. He was transferred to BJH on 9-20-00 for further management. Upon arrival to the NNICU the patient was awake and intubated with a right ventriculostomy catheter in place. Neurological examination of the patient showed he was awake with eyes open, regarding the examiner but not following commands. His pupils were equal and reactive, and brainstem reflexes were intact. Repeat head CT obtained on 9-20-00 revealed extensive intracerebral hemorrhage, including subarachnoid blood along the left convexity of the Sylvian fissure and layering in the occipital horns of the lateral ventricles, intraparenchymal blood in the frontal lobes bilaterally, in the left cerebellum, in the anterior right temporal lobe, and bilateral occipital subdural hematomas. On 9-21-00 diagnostic cerebral angiography was performed which revealed a 10 mm diameter aneurysm and no evidence of cerebral vasospasm. On 9-22-00 GDC coils were placed within the aneurysm by interventional neuroradiology. The procedure was complicated by loss of anterograde flow through the A2 segment of the left anterior cerebral artery with retrograde filling of that artery from pial collaterals. On 9-23-00 a sustained focal motor seizure involving right-sided twitching was noted which aborted with IV Ativan. On 9-24-00 the ventriculostomy catheter was removed from the right side and a new ventriculostomy catheter was placed on the left side. The patient had episodic fevers between 9-22-00 and 9-27-00 without an obvious infectious source and paroxysmal atrial fibrillation requiring IV diltiazem for rate control. He was extubated 9-26-00 and was neurologically unchanged from admission. The ventriculostomy catheter was removed on 10-3-00. He was transferred to the floor on 10-4-00. A gastrostomy tube was placed on 10-9-00. His subsequent course was not remarkable until 10-15-00, when he was found apneic and pulseless on the floor..
