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A 49-year-old man with history of hypertension and hyperlipidemia presents with a sudden onset of severe bifrontal headache followed by nausea. The patient vomited on his way to the nearby emergency department (ED) and became obtunded in the ambulance. On arrival to the ED, he was intubated for airway protection as his mental status continued to worsen. About 30 minutes after the onset of the initial symptoms, he progressed to stuporous mental status with minimal but intact withdrawal responses to painful stimulation. Brainstem reflexes were intact. Stat head computed tomography (CT) (Figure 1-1) revealed acute subarachnoid hemorrhage (SAH) filling the basal cistern, bilateral sylvian fissures with thick hemorrhages along with early radiographic evidence for hydrocephalus, and intraventricular hemorrhage (IVH) mainly in the fourth ventricle. The local ED physicians decided to transfer the patient immediately to the nearest tertiary medical center. During the emergent transfer, patient stopped responding to any painful stimuli and had only intact brainstem reflexes.

On arrival at the neurologic intensive care unit, the following is the clinical observation: Patient is intubated with endotracheal tube, in coma, decerebrate posturing on painful stimulation, intact corneal reflexes, pupils 5 mm in diameter briskly constricting to 3 mm bilaterally to the light stimulation, intact oculocephalic reflexes, and positive bilateral Babinski signs.

Vital signs: HR 110 bpm in sinus tachycardia, RR 20 breaths/min on the set rate of 14 breaths/min on assist control–volume control mechanical ventilation, temperature: 99.3°F, BP: 190/100 mm Hg by cuff pressure on arrival to the NeuroICU.

Figure 1-1.

Axial CT images of the brain without contrast.

What are the initial steps for resuscitating acute aneurysmal subarachnoid hemorrhage in this case?

The clinical and radiographic presentation of this case is consistent with high-grade (initially Hunt and Hess [HH] grade IV, then quickly progressing to grade V in transit to the tertiary care center) acute SAH. Airway, breathing, and circulation (ABC) have all been addressed, although the blood pressure is high at this time. The very first step in managing this patient is ventricular drain, the second step is ventricular drain, and the third step is ensuring that the ventricular drain you have just placed is working (ie, draining the hemorrhagic cerebrospinal fluid [CSF] adequately when the drain is kept open, and maintaining good waveforms when the drain is clamped). After ABC, placing external ventricular drain (EVD) is the most crucial, lifesaving, important early step for managing the patients with high-grade acute SAH with poor mental status and IVH. The presence of IVH complicates the natural course of both intracerebral hemorrhage (ICH) as well as SAH cases. IVH is often associated with development of an acute obstructive hydrocephalus, which may lead to vertical eye movement impairment and depressed level of arousal by its mass effect on the thalamus and midbrain. IVH is also associated with elevated intracranial pressure ...

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