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Washington University Experience | VASCULAR | Aneurysm - Saccular | 9A0 Case 9 History
Case 9 History ---- The patient was a 44-year-old man with a past medical history of hypertension, alcohol and tobacco use, and an episode of upper gastrointestinal bleeding in 2005 that was attributed to a Mallory-Weiss tear. On 3/10/12, he experienced abrupt onset left shoulder and neck pain at approximately 05:15 PM, and presented to an outside facility at 06:00 where he was evaluated and found to be acting abnormally. He endorsed using heroin at that time and was given Narcan with improvement of his mental status. At approximately 9:00 PM, he had a seizure which was treated with Ativan. CT of the head revealed a large left frontal intraparenchymal hemorrhage as well as widespread subarachnoid hemorrhage. His last sedation (he had become combative) was given at approximately 09:30 and he was sent to BJH where he arrived comatose. He did not open eyes or regard, or follow commands. His right pupil was 5 mm, irregular and fixed. His left pupil was 6 mm, irregular and fixed. He had no doll's response or corneal reflexes, and did not grimace to painful stimulation. Serum ethanol levels and drug screen were negative. A complete metabolic panel was unremarkable. Complete blood count revealed leukocytosis. CT of the head revealed diffuse thick subarachnoid hemorrhage with an area of irregularity around the left A1/A2 junction, a 6.5 cm left frontal intraparenchymal hemorrhage extending from that location, a 16 mm left to right midline shift, enlargement of the right temporal horn suggestive of ventricular entrapment, and thick subarachnoid blood surrounding the basal cisterns. The clinical prognosis was considered dismal with only partial brainstem function. The family asked to continue maximal medical therapy. The patient was maintained in the ICU on vasopressors but his condition declined until brain death was documented at 0800 on 3/11/12.
