Neurosurgery

Case summary

A 70-year-old woman was admitted to hospital following an episode of collapse with neurological symptoms. She had a history of neck pain over the previous week. She was initially assessed for possible stroke. Subsequent scans showed evidence of subarachnoid haemorrhage (SAH) and a basilar tip aneurysm.

The next day, the patient was transferred to the local neurosurgical unit 30 kms away. On arrival she was documented to be alert, with symptoms of headache. The aneurysm was treated endovascularly with coil embolisation the following afternoon. No problems or complications with the procedure were documented.

On return to the ward, the patient was noted to be initially drowsy in recovery, but she improved to alertness. A couple of hours later, she showed reduced consciousness, with new facial and limb weakness and slurred speech. A computed tomography (CT) scan showed no acute changes. She was managed with fluid hydration. Her consciousness fluctuated overnight, with a Glasgow Coma Scale score ranging from 10 to 15. Arrangements were made for transfer to the intensive care unit (ICU) for blood pressure and fluid support to manage the presumed diagnosis of delayed cerebral ischaemia.

The following morning, while still on the ward, the nurse documented that the patient was alert and oriented. The nurse left to make arrangements for transfer to ICU and returned to find the patient unresponsive and in cardiac arrest. A medical emergency team call was initiated and immediate resuscitation procedures commenced. Return of spontaneous circulation was obtained 15 minutes into cardiopulmonary resuscitation. 

The patient was transferred to ICU, where pulmonary oedema was noted. Further CT scans revealed no new changes. Another cardiac arrest occurred requiring resuscitation. Maximum oxygen and blood pressure support alongside mechanical ventilation were required. 

The patient never regained consciousness over the subsequent six days in ICU, and later scans showed areas of brain ischaemia. Comfort measures were implemented after family discussions and the patient died on day eight of admission to the neurosurgical hospital.

Discussion

There was a delay in getting this patient to ICU after neurological concerns were noted on the ward. Unfortunately, with SAH there remains a risk of rapid systemic complications, despite a patient presenting with a relatively good neurological grade with alert orientation and no initial persisting neurological deficit. Delayed cerebral ischaemia (whether directly related to vasospasm or not), myocardial stunning and neurogenic pulmonary oedema are known major complications of aneurysmal SAH, with high morbidity and mortality.
Appropriate measures of fluid bolus and CT scanning were undertaken immediately. The scan excluded a new haemorrhage or hydrocephalus. When there were no acute structural changes, delayed ischaemia was considered. Arrangements for ICU management were made overnight—as further fluctuations to consciousness were recorded—although the planned transfer to ICU did not occur until the following morning.

Rapid onset of severe delayed cerebral ischaemia and its effects may still have occurred, despite maximum ICU blood pressure and fluid support. However, the opportunity to initiate such maximal therapy should have been undertaken as soon as the consideration of delayed cerebral ischaemia was made, especially in a treated and protected aneurysm. Any pulmonary and cardiac complications arising during ICU management could then have been managed more expeditiously to limit the additional effects of a prolonged hypoxic arrest. 

The initial neurosurgical management following admission is entirely appropriate. No other concerns were raised from the remainder of the ICU management.

Clinical lessons

A rapid decline from the various systemic effects of an aneurysmal SAH can occur, even after treatment of the aneurysm itself. A patient may fail to respond to maximal therapy even after such complications are identified. The earliest intensive management of suspected delayed cerebral ischaemia should be initiated if facilities are available, especially in a case that presented with initial good neurological grade.