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Washington University Experience | VASCULAR | Herniation, uncal | 8A0 Case 8 History
Case 8 History ---- The patient was a 50 year old man with history of hypertension, coronary artery disease status/post stent placement, alcoholism, tobacco use (1 pack/day x years) and depression. On April 10, he presented to an outside hospital requesting detoxification, complaining of suicidal ideations and had increased drinking up to a fifth of whisky daily. He was admitted. He was noted to be ambulatory and conversant, oriented x3, with no focal neurological abnormalities. His alcohol level was 203 mg/dL. He was given multivitamins, folic acid, thiamine, and 1 gram of magnesium sulfate. There was no evidence of active withdrawal or an active toxic syndrome. The patient was given a total of 4 mg Ativan (lorazepam) intravenously for comfort. At the time of admission, he complained of episodic chest discomfort. EKG showed normal sinus rhythm without evidence of ST elevation and he was given 2 baby aspirins. After medical clearance, the patient was admitted for psychiatric care and detoxification. On April 11 at 8:40 AM, the patient complained of back pain. At 10:30 AM, he complained of the worst headache of his life. He was given 2 mg intravenous Ativan x2 and became more lethargic with slurred speech. Around 11:30 AM, the patient was found unconscious in his room, not responding to any stimuli with a Glasgow Coma Scale score of 4. In a consultation note, there was a suspicion for an unwitnessed traumatic fall in the room. His blood pressure was around 210-220 systolic and 100-120 diastolic, with a heart rate in 40s. A head CT scan showed a large, likely ongoing right subdural hemorrhage and extremely severe right-to-left, right uncal and transtentorial downward herniation. There was also evidence of edema and sulcal effacement. The patient was emergently intubated, given 100 mg mannitol and transferred to BJH for immediate neurosurgical intervention. In route, the patient hyperventilated with a pCO2 of less than 35. No sedation was given. On arrival to the BJH ICU, the patient was comatose, intubated, with nonreactive bilateral pupils, negative corneal reflex, negative vestibulo-ocular reflex, minimal cough/gag reflex, no response to sternal rub and triple flexion of his lower extremities. A repeat head CT showed worsening subdural hemorrhage with midline shift. The Neurosurgery service was consulted and determined the patient was not a candidate for surgical intervention. The family decided to redirect care and the patient expired April 12.
