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SAH Grade IV MMM Case Study

SAH Grade IV MMM Case Study. Stephan Mayer Columbia University. SAH. 57 year old woman with a history of MS and seizure disorder Sudden episode of LOC on 5/28 described as frozen expression on face, became tense and slumped backwards with eyes rolling back.

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SAH Grade IV MMM Case Study

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  1. SAH Grade IV MMM Case Study Stephan Mayer Columbia University

  2. SAH • 57 year old woman with a history of MS and seizure disorder • Sudden episode of LOC on 5/28 described as frozen expression on face, became tense and slumped backwards with eyes rolling back. • EMS was activated and patient was taken to the ED where she was noted to be awake and alert and in "no actue distress" • Her vitals at the time were 97.1° 80 22 191/88. • Afetr arriving in the ED she had a GTC and was intubated for airway protection

  3. Admission CT

  4. Angiography

  5. Post Op CT

  6. Bundle Placement

  7. EXAM • Coma • 3 mm sluggish pupils • Does not doll or gag; no corneals • Responds to deep pain by flexing both arms and legs • Toes are down

  8. MANAGEMENT • Gave amicar to prevent rebleeding • CPP 60-70 control with nicardipine • Phenytoin • Nimodipine; 3% saline at 75 ml/kg, sodium goal of 150. • Hold lovenox for now

  9. EVENTS • Day 4 -- febrile --given cold saline -- stopped dilantin and started keppra; stopped steroids; started on antibiotics • Has PLEDS on the right side per EEG • Day 5 – CTP shows diffuse hyperemia

  10. CT Perfusion

  11. EVENTS • Day 6 -- Added phenytoin for seizures. Also had episodes of increased ICP in the mid 20's, likely in the setting of shivering, which responded to buspirone, tylenol and meperidine. • She was also started on levophed to maintain her BP and keep her CPP >100. • Day 7 -- CTA c/w mild-moderate vasospasm especially ACAs. By now following some 1-step commands. • Day 8 -- angiogram shows moderate diffuse distal spasm, given IA verapamil, no angioplasty

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