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Washington University Experience | VASCULAR | Aneurysm - Saccular | 6A0 Case 6 History
Case 6 History ---- The patient was a 40 year old right handed woman who was first seen at an OSH on 2/l/89 for sudden onset of severe right frontal and occipital, nuchal headache with transient blurring of vision. On physical exam she was alert and oriented with clear speech and a completely nonfocal neurological exam. An LP showed hemorrhagic xanthochromatic CSF (270K RBCs, 300 WBCs, a protein of 820 and a glucose of 62. A head CT showed widespread subarachnoid hemorrhage, especially at the base of the brain. Angiography at BJH revealed a 5-7 mm right pericallosal artery aneurysm with a 3 mm neck and a lobulated 7 mm basilar aneurysm originating between the right superior cerebellar and the right posterior cerebral arteries. The patient underwent a left ventriculostomy because of mild lethargy and slight prominence of the temporal horn on CT but had to be removed after 24 hours secondary to clotting. Perioperatively the patient was started on vancomycin and flagyl. On 2/3 the patient had sudden onset of sharp pain in her head with subsequent eye deviation to the right, tonic extension of the right upper extremity and unresponsiveness with an apneic type respiratory pattern". Her pupils were dilated and reactive. She was rapidly intubated and a right ventriculostomy was placed. Pupils were small and reactive. She had positive doll’s eyes with less left gaze preference and left exotropia. Corneal reflexes and gag were intact. Repeat CT was consistent with a re-bleed. On 2/4 the patient remained unresponsive and had downward deviation of her eyes with present horizontal and absent vertical oculocephalics. The ventriculostomy was draining CSF. A transcranial Doppler demonstrated elevated blood flow velocities not consistent with vasospasm. She had intermittent temperature spikes up to 39.5 that were treated with a combination of vancomycin and Flagel. On the day of her extubation the patient developed anisocoria with a dilated and eventually unreactive right pupil as well as a partial right third nerve with an adduction deficit. She continued to have a left hemiparesis and spontaneously only moved her right upper extremity. In spite of draining ventriculostomies follow up CT on 2/12 showed increasing ventricular size and lucencies in both frontal lobes. Medically her course was complicated by a fungal UTI that was treated with amphotericin bladder irrigation and purulent conjunctivitis without an identifiable organism as well as intermittent temperatures up to 39. The patient underwent VA shunt placement on 2/27 without change in her neurological exam. On 3/6 the patient was found apneic and CPR was not successful.
