Cerebral vasospasm

Subarachnoid hemorrhage (SAH) represents bleeding into the subarachnoid space, most commonly from a ruptured cerebral aneurysm. There are approximately 30,000 patients with SAH per year in the USA making it a commonly encountered disease in the neurologic intensive care unit (ICU). Case description. A 52-year-old right-handed female with a medical history of smoking and hypertension developed the abrupt onset of a severe bifrontal headache. She was taken to a local emergency department where a head computed tomography (CT) revealed a Fisher 3 SAH with moderate hydrocephalus. Her initial exam was stuporous but arousable with intact cranial nerve responses. She was able to follow commands with stimulation. An external ventricular drain was placed with improvement in her mental status. Cerebral angiography revealed an 8 mm anterior communicating artery aneurysm that was treated with coil embolization. The patient was then transferred to the neurologic ICU. Intravenous magnesium and oral nimodipine were started for cerebral vasospasm prophylaxis. Five days posthemorrhage she developed a worsening of her headache. Her serum sodium decreased from 143 mOsm/L to 132 mOsm/L. The following day she developed progressive right-sided weakness and word-finding difficulties. Repeat cerebral angiography revealed severe vessel narrowing of the left middle and anterior cerebral arteries (Figure 80.1). She was given aggressive volume replacement with normal saline and her mean arterial blood pressure was increased to 110 mmHg with intravenous phenylephrine. She had improvement but not complete resolution of her signs and symptoms.