Background: Multimodal monitoring to guide medical intervention in high-grade aneurysmal subarachnoid hemorrhage (aSAH) is well described. Multimodal monitoring to guide surgical intervention in high-grade aSAH has been less studied.
Observations: Intracranial pressure (ICP), brain lactate to pyruvate ratio (L/P ratio), and brain parenchymal oxygen tension (pO2) were used as surrogates for clinical status in a comatose man after high-grade aSAH. Acute changes in ICP, L/P ratio, and pO2 were used to identify brain injury from both malignant cerebral edema and delayed cerebral ischemia, respectively, and decompressive hemicraniectomy with clot evacuation and intraarterial nimodipine were used to treat these conditions. The patient showed marked improvement in multimodal parameters following each intervention and eventually recovered to a modified Rankin score of 2.
Lessons: In patients with a limited neurological examination due to severe acute brain injury in the setting of aSAH, multimodal monitoring can be used to guide surgical treatment. With prompt, aggressive, maximal medical and surgical interventions, otherwise healthy individuals may retain the capacity for close to full recovery from seemingly catastrophic aSAH.
Keywords: CSF = cerebrospinal fluid; CT = computed tomography; DCI = delayed cerebral ischemia; GCS = Glasgow Coma Scale; ICP = intracranial pressure; L/P ratio = lactate-to-pyruvate ratio; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage; aSAH = aneurysmal subarachnoid hemorrhage; cerebral microdialysis; delayed cerebral ischemia; multimodal monitoring; pO2 tension = parenchymal oxygen tension; subarachnoid hemorrhage; vasospasm.
© 2022 The authors.