Subarachnoid bleeding...thoughts?

[Gerg]

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We're doing some case studies, and a bunch of us have come to a dead end. We've come up with some thoughts, but I thought maybe some of you could offer some.

A 58 year old male is admitted to the ER after an episode of loss of consciousness preceded by a severe headache associated with vomiting, neck pain and photophobia. The patient is also complaining of double vision and inability to fully open his left eye. A non-contrast CT scan of the head is obtained and reveals blood in the subarachnoid space. Four vessel cerebral angiography is then performed and reveals an aneurysm of the left posterior communicating artery amenable for surgical clipping.

Because we're doing anatomy, a lot of the things we're learning is how nerve damage (specifically Cranial Nerve dmg) for these cases will affect the pt (ie, double vision, droopy left eye).

What we're trying to figure out is the neck pain and vomiting. After consideration, we've come to the conclusion that it's due to the Subarachnoid bleeding.. just say extra blood in there will cause "bad" pressure and screw up all kinds of stuff.

Any thoughts on specific mechanisms to cause these symptoms, given the fact that there is blood in there?

Thanks.

 

[saiyagirl]

We're doing some case studies, and a bunch of us have come to a dead end. We've come up with some thoughts, but I thought maybe some of you could offer some.

A 58 year old male is admitted to the ER after an episode of loss of consciousness preceded by a severe headache associated with vomiting, neck pain and photophobia. The patient is also complaining of double vision and inability to fully open his left eye. A non-contrast CT scan of the head is obtained and reveals blood in the subarachnoid space. Four vessel cerebral angiography is then performed and reveals an aneurysm of the left posterior communicating artery amenable for surgical clipping.

Because we're doing anatomy, a lot of the things we're learning is how nerve damage (specifically Cranial Nerve dmg) for these cases will affect the pt (ie, double vision, droopy left eye).

What we're trying to figure out is the neck pain and vomiting. After consideration, we've come to the conclusion that it's due to the Subarachnoid bleeding.. just say extra blood in there will cause "bad" pressure and screw up all kinds of stuff.

Any thoughts on specific mechanisms to cause these symptoms, given the fact that there is blood in there?

Thanks.

here's what i think - the neck pain is due to the irritation of the meninges causing neck pain upon flexion (is it only upon flexion?)...that's called meningismus

vomiting--the increased intracranial pressure might be compressing the medulla, where the autonomic center for vomiting is located.

what was the answer, finally?

 

[sponch]

Headache, neck pain, vomiting, photophobia. Sounds like meningitis! Perhaps he was bacteremic and some bugs got into the CSF. Transient bacteremia is common -- about half of the time that you brush your teeth you will get bugs in your blood.

We're doing some case studies, and a bunch of us have come to a dead end. We've come up with some thoughts, but I thought maybe some of you could offer some.

A 58 year old male is admitted to the ER after an episode of loss of consciousness preceded by a severe headache associated with vomiting, neck pain and photophobia. The patient is also complaining of double vision and inability to fully open his left eye. A non-contrast CT scan of the head is obtained and reveals blood in the subarachnoid space. Four vessel cerebral angiography is then performed and reveals an aneurysm of the left posterior communicating artery amenable for surgical clipping.

Because we're doing anatomy, a lot of the things we're learning is how nerve damage (specifically Cranial Nerve dmg) for these cases will affect the pt (ie, double vision, droopy left eye).

What we're trying to figure out is the neck pain and vomiting. After consideration, we've come to the conclusion that it's due to the Subarachnoid bleeding.. just say extra blood in there will cause "bad" pressure and screw up all kinds of stuff.

Any thoughts on specific mechanisms to cause these symptoms, given the fact that there is blood in there?

Thanks.

 

[Seaglass]

Headache, neck pain, vomiting, photophobia. Sounds like meningitis! Perhaps he was bacteremic and some bugs got into the CSF. Transient bacteremia is common -- about half of the time that you brush your teeth you will get bugs in your blood.

Maybe you missed the part about the subarachnoid beeding. Anyway, the "worst headache of my life" is the typical presentation of SAH (subarachnoid hemorrhage) and frequently has vomiting and neck pain due to the increased intracranial pressure asssociated with the bleeding.

 

[Gerg]

Thanks to everybody.

 

[Whisker Barrel Cortex]

The neck pain is most likely due to meningeal irritation from the SAH. The nausea and vomiting can be caused by either increased ICP or chemical meningitis from heme.

 

[southerndoc]

I think saiya gave an excellent answer.

As Seaglass pointed out, many patients describe SAH headaches as the worst headaches of their life. Very frequently they describe them as full intensity from the onset. Usually you can get a good feel if you ask if it gradually built up over a period of minutes (as a migraine does) or if it was like a thunderclap (full intensity immediately). However, any unexplained headache should get an LP no matter what the presentation. So if you can't explain it, then tap it. (Migraines is an explanation, so this doesn't mean that EVERY headache gets an LP.)

 

[Mumpu]

Agree with above. If you want to think one step ahead (the key to being a star student) check the guy's kidneys while you are at it. Adult polycystic kidney disease is associated with berry aneurysms.

Southern, correct me if I'm wrong but I was under the impression that increased ICP and brain abscesses are a contraindication to LP.

 

[Seaglass]

They are a relative contraindication. Generally speaking, unless there is some coexisting pathology that concerns you in the setting of a stone-cold normal neuro exam then you can go ahead with the LP. Some examples of concerning pathology would be any new neuro finding, papiledema, vision changes, severe disease (kid with shunt for example).

 

[Mumpu]

Thanks for clarifying that bit.

 

[Whisker Barrel Cortex]

Agree with above. If you want to think one step ahead (the key to being a star student) check the guy's kidneys while you are at it. Adult polycystic kidney disease is associated with berry aneurysms.

Southern, correct me if I'm wrong but I was under the impression that increased ICP and brain abscesses are a contraindication to LP.

If you need an LP for the diagnosis you do it anyway. You just notify neurosurgery beforehand in case they are needed emergently.

 

[Seaglass]

I suppose if you thought they really might herniate or had something suggestive on CT you would notify neurosurg, but in reality we almost never do because if we did we would have to call them ~10 times a day.

 

[neuropain]

Occulomotor nerve also passes very close to the PCA.... That can cause ptosis....