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Washington University Experience | VASCULAR | Aneurysm - Saccular | 19A0 Case 19 History
Case 19 History ---- This patient was a 44 year-old woman with a history of hypertension who presented to the BJH ER on 10/30/04 with headache and altered mental status. On initial exam in the ED she was alert, oriented, and following commands. BP was elevated to 220/110. Head CT showed subarachnoid blood in the basilar cisterns and a subdural hematoma (SDH), most pronounced over the left tentorium. In the ED the patient had a witnessed seizure with decline in her mental status and extension of the SDH on repeat CT. She was admitted to neurosurgery. Cerebral angiography revealed 6 aneurysms. The largest, measuring 1x1.5 cm, was located at the origin of the left posterior communicating artery and was the suspected source of bleeding. Other aneurysms were located on the left anterior choroidal artery, left internal carotid artery terminus, right MCA bifurcation, right posterior communicating artery and right pericallosal artery. Following the seizure, the patient was unresponsive with a fixed and dilated left pupil. She therefore underwent emergent left frontotemporal craniotomy, evacuation of the underlying hematoma, and clipping of 3 of the aneurysms including the left posterior communicating artery. An intracranial pressure monitor was placed. The following day she returned to the OR for decompressive left frontotemporoparietal craniotomy. Slow, minimal improvement was noted in her neurologic exam. Prolonged ventilatory support was required, with the patient eventually weaned off the vent after tracheostomy placement. A G-J tube was placed for nutritional support. The patient remained stable during a prolonged period of discharge planning. She was transferred to a skilled nursing facility on 12/17/04. The following day the patient was readmitted. Head CT revealed infarcted tissue herniating through the left fronto-parieto-temporal craniotomy defect. The patient became progressively more bradycardic during this admission. On 12/20/04 the patient was found unresponsive with pulseless electrical activity. Resuscitation efforts were unsuccessful.
