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Washington University Experience | VASCULAR | Aneurysm - Saccular | 5A0 Case 5 History
Case 5 History ---- This 45 year old right handed male construction supervisor presented to an OSH hospital in Highland, Ill on April 20 with complaints of a right frontal headache. Blood pressure was 200/100 and neurologic exam was said to be normal. He was treated with Demerol and Lasix and sent home. Ten hours later, his headache was very severe. He was unable to sleep and collapsed unresponsive on the floor. He was returned to the ER by his wife. He was lethargic and complaining bitterly of a headache. Lumbar puncture showed bloody fluid. Sketchy history from the outside hospital reveals that two hours following admission there he had a respiratory arrest and was placed on a ventilator. He had a 50 pack year smoking history and was a beer drinker. On arrival at Barnes on April 21, his blood pressure was 150/100 and he was deeply comatose with Cheynes-Stokes respirations. Pupils were 3/3 and no light reaction was detected. There were no Doll's eyes or movement to ice water calorics. Tendon reflexes were 2+ with normal tone, toes were extensor bilaterally. A CT scan showed moderately severe internal hydrocephalus with subarachnoid and intraventricular blood in both lateral ventricles and the 3rd ventricle. A right frontal ventriculostomy was performed. The fluid was under "low pressure" and was bloody. He was treated with Decadron, Aldomet, Cimetidine, and respiratory support. Apresoline was given on prn basis. Eight hours after admission, there was some movement to ice water calorics and purposeful movements to deep pain. The following day there were intact Doll's eyes the left, and he localized pain in the left upper extremity. There was no movement in the right upper extremity to pain. On April 23, a four vessel angiogram was performed which showed a left vertebral aneurysm, 1. 5 x 1 cm, which was 1 cm ·proximal to the ·basilar artery. Spasm in both vertebral arteries was present. By April 26, the patient was extubated, he spoke his name, and followed a few simple commands. His pupils were 3/3, round and reactive to light. Extra-ocular movements showed minimal medial movement and no movement bilaterally. He moved all extremities but there was a relative right hemiparesis. A repeat CT scan on April 29 showed the ventricles still bloody. Left ventricle greater than the right ventricle in size. A VA shunt was placed. During the next days, the patient was somewhat less responsive. Speech was slurred and he did not follow commands. There was minimal movement to pain. Shunt taps revealed no evidence of malfunction of the VA shunt and repeat CTs were unchanged except for gradual clearing of the intraventricular blood. A urinary tract infection was discovered and was treated with Ampicillin, later switched to Septra. On May 27, he was awake, followed simple commands, and answered simple questions. Eyes remained medially deviated at neutral position with absent lateral volitional movement. Pupils were sluggish, there was a mild right hemiparesis. On May 30th he was awake and alert but later was found without vital signs. CPR was initiated without success.
