Berry, Bored, Bleeding - Review

It’s 3 am and the ED has fallen into a lull. There is only a trickle of patient’s seeking for a a work note, though you’d believe their farfetched complaints if it weren’t for your wise attending.

Enter the headache. Before you are able to dismiss yet another malingerer, this 55 year old woman tells you that this is the worst headache she has ever had, and that it woke her up from sleep.

Before you notice, this patient slides into a state of altered mental status and vomits.

What is the most likely/feared etiology and what ECG changed do you expect to find in this patient?

This is most likely a subarachnoid hemorrhage (SAH) due to a ruptured aneurysm (75% of SAH).

EKG changes in raised intracranial pressure include:

Diffuse large inverted T waves with “bizarre morphology”.
QT prolongation.
Bradycardia (“Cushing reflex” – late finding indicative of herniation).
Ischemic ST changes.

(http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/SAH1.jpg

Seven days later you happen to be in the SICU and are called for this same patient who you admitted for a new neurological deficit. Repeat CT is neg for re-bleed.

Presuming ischemia, what is the most likely etiology of this delayed phenomenon and how do you treat?

Vasospasm.

Clinically significant vasospasm occurs in 20-30% of SAH.
Occurs between 2 days and 3 weeks (peaks at 7 days).
Manifests as new neurological deficit or declining neurological status.
Imaging studies: Transcranial Doppler (less reliable due to user dependence). CT angiogram and CT perfusion.

Treatment:

Nimodipine (more specifically, 60mg PO/NGT every 4 hours).

Should start within 96 hours of symptoms.
Nimodipine more than other CCB has been shown to decrease adverse outcomes (NNT 13 to prevent one poor outcome).

References:

Lifeinthefastlane.com – Raised intracranial pressure
Tintinalli, Judith E., Gabor D. Kelen, and J. Stephan. Stapczynski. Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill, Medical Pub. Division, 2004. Print.

Scroll down for Amal Matu ECG of raised intracranial pressure.